Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma

OBJECTIVE

To assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI).

MATERIALS AND METHODS

Single center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications.

RESULTS

Overall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR.

CONCLUSIONS

Complications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

Robot-assisted vs. open radical cystectomy: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several randomized controlled trials (RCTs) have been launched in the last decade to examine the surgical safety and oncological efficacy of robot-assisted (RARC) vs open radical cystectomy (ORC) for patients with bladder cancer. The aim of the study was to perform a systematic review and meta-analysis of RCTs to compare the perioperative and oncological outcomes of RARC vs ORC.

METHODS

A literature search was conducted through July 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The outcomes were intraoperative, postoperative, and oncological outcomes of RARC vs ORC.

RESULTS

A total of eight RCTs comprising 1,024 patients met our inclusion criteria. RARC was associated with longer operative time (mean 92.34 min, 95% CI 83.83-100.84, p < 0.001) and lower blood transfusion rate (Odds ratio [OR] 0.43, 95% CI 0.30-0.61, p < 0.001). No differences emerged in terms of 90-day overall (p = 0.28) and major (p = 0.57) complications, length of stay (p = 0.18), bowel recovery (p = 0.67), health-related quality of life (p = 0.86), disease recurrence (p = 0.77) and progression (p = 0.49) between the two approaches. The main limitation is represented by the low number of patients included in half of RCTs included.

CONCLUSIONS

This study supports that RARC is not inferior to ORC in terms of surgical safety and oncological outcomes. The benefit of RARC in terms of lower blood transfusion rate need to be balanced with the cost related to the procedure.

A Study on How Food Colour May Determine the Categorization of a Dish: Predicting Meal Appeal from Colour Combinations

A person’s preference to select or reject certain meals is influenced by several aspects, including colour. In this paper, we study the relevance of food colour for such preferences. To this end, a set of images of meals is processed by an automatic method that associates mood adjectives that capture such meal preferences. These adjectives are obtained by analyzing the colour palettes in the image, using a method based in Kobayashi’s model of harmonic colour combinations. The paper also validates that the colour palettes calculated for each image are harmonic by developing a rating model to predict how much a user would like the colour palettes obtained. This rating is computed using a regression model based on the COLOURlovers dataset implemented to learn users’ preferences. Finally, the adjectives associated automatically with images of dishes are validated by a survey which was responded by 178 people and demonstrates that the labels are adequate. The results obtained in this paper have applications in tourism marketing, to help in the design of marketing multimedia material, especially for promoting restaurants and gastronomic destinations.

POS0185 BELIMUMAB DISRUPTS MEMORY B-CELL TRAFFICKING IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Belimumab (BEL), a recombinant human monoclonal antibody directed against B-cell activating factor (BAFF), is the first approved biological agent for patients with active systemic lupus erythematosus (SLE) and lupus nephritis (LN).1 BEL inhibits primary humoral immune responses by depleting naïve B cells that are dependent on BAFF for their survival while secondary humoral immune responses by memory B cells (MBCs) remain intact. Indeed, some studies reported an increase of circulating MBCs following neutralisation of BAFF.2-4 So far, these effects of BEL on the MBC compartment in SLE patients have not been investigated.

Objectives

This study aimed to establish the dynamics of circulating MBCs in patients with SLE treated with BEL and to perform an in-depth analysis of the impact of BEL on the MBC compartment.

Methods

First, a retrospective meta-analysis was performed by pooling individual patient MBC flow cytometry data from 1245 patients with SLE treated with BEL 10 mg/kg IV or placebo (PBO) from four randomised clinical trials (NCT00071487, NCT00410384 [BLISS-76],3NCT01632241 [EMBRACE],5NCT01649765 [PLUTO]6). Second, extensive B-cell subset phenotyping was performed prospectively by employing high-sensitivity flow cytometry (HSFC) based on EuroFlow protocols7 in patients with active SLE (from the BLISS-BELIEVE trial [NCT03312907])8 and with severe SLE/LN (from the SynBioSe-2 trial [NCT03747159])9 treated with BEL. Additionally, in-depth characterisation of surging MBCs in circulation was performed by single-cell RNA sequencing (scRNA-seq).

Results

By comparing BEL-treated with PBO-treated patients with SLE, a substantial increase in circulating MBC counts was established 4 weeks after BEL initiation, gradually returning to baseline by Week 52. The increase of MBCs was most prominent in BEL-treated patients with higher SLE disease activity (SLE Disease Activity Index >9), serologically active patients (dsDNA positive and/or low complement levels) and with younger age (below 18 years). HSFC established that the increase was non-specific and observed in a broad range of MBC subclasses peaking as early as 2 weeks after BEL initiation. Subsequent scRNA-seq analysis of the emerging MBCs revealed a non-proliferating phenotype with a prominent decrease in activation status. In these circulating MBCs, a large amount of migration and adhesion genes were downregulated suggesting that the accumulation of MBCs following BEL treatment was related to their impaired cell-cell adhesion, disrupting cell-trafficking and preventing extravasation.

Conclusion

After initiation of BEL treatment, a substantial increase of circulating MBCs was firmly established and was most notable in patients with severe, serologically active SLE/LN. The surge of circulating MBCs appeared to be associated with disrupted lymphocyte trafficking of MBCs, thereby suggesting a new potential therapeutic mechanism of BEL on MBCs in SLE. These findings have important implications to our understanding and consequent improvement of B-cell targeted treatment strategies in patients with active SLE and LN, as MBC accumulation in circulation might allow for more efficient targeting of the B-cell compartment.

References

[1]GlaxoSmithKline. Benlysta US prescribing information. 2021

[2]Wallace DJ, et al. Arthritis Rheumatol 2009;61(9):1168–78

[3]Furie R et al. Arthritis Rheumatol 2011;63(12):3918–30

[4]Stohl W et al. Arthritis Rheumatol 2012;64(7):2328–37

[5]Ginzler E et al. Arthritis Rheumatol 2022;74(1):122–3

[6]Dimelow R et al. Clin Pharmacol Drug Dev 2021;10(6):622–33

[7]Blanco E et al. J Allergy Clin Immunol 2018;141(6):2208–19

[8]Teng YKO et al. BMJ Open 2019;9(3):e025687

[9]ClinicalTrials.gov NCT03747159. Accessed January 19 2022

Acknowledgements

This analysis of the GSK Study 205646 was funded by GlaxoSmithKline (GSK). Editorial support was provided by Nicholas Thomas, PhD, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK. The EuroFlow-based HFSC was technically supported by Alita van der Sluijs and Sandra de Bruin and data acquisition was performed at the Flow cytometry Core Facility of Leiden University Medical Center, Leiden, NL.

Disclosure of Interests

Eline J. Arends: None declared, Mihaela Zlei Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Christopher M. Tipton: None declared, Jasna Cotic Shareholder of: GSK, Employee of: GSK, Zgjim Osmani: None declared, Fenna de Bie Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Sylvia Kamerling: None declared, Andre van Maurik Shareholder of: GSK, Employee of: GSK, Richard Dimelow Shareholder of: GSK, Employee of: GSK, Yun Irene Gregan Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Ton Rabelink: None declared, David Roth Shareholder of: GSK, Employee of: GSK, Ignacio Sanz Consultant of: Yes. GSK, BMS, Janssen, Kyverna, Jacques J.M. van Dongen Consultant of: BD Biosciences and Cytognos (fees for LUMC), Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Cees van Kooten: None declared, Y.K. Onno Teng Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, KezarBio, Grant/research support from: GSK

POS0680 BELIMUMAB ADD-ON THERAPY MOBILISES MEMORY B CELLS INTO THE CIRCULATION OF PATIENTS WITH SLE

Background:

Belimumab (BLM), a recombinant human monoclonal antibody directed against B-cell activating factor (BAFF), is the first approved biological agent for patients with active severe systemic lupus erythematosus (SLE) and lupus nephritis (LN). There is clinical evidence that combining BLM with B cell depleting therapy can ameliorate disease activity in severe, refractory SLE patients1. Although BLM is a B cell directed therapy and has been shown to significantly decrease total B cells, flow cytometry observations suggest a rapid increase of circulating memory B cells (MBC)2.

Objectives:

To investigate dynamics of B-cell subsets in SLE patients treated with or without BLM, with a focus on assessing MBC characteristics.

Methods:

Extensive B cell subset phenotyping was performed by high-sensitivity (HS) flow cytometry (acquisition of 107 leukocytes; per EuroFlow protocols3) on samples from active LN or SLE patients with major organ involvement treated with standard of care (SOC) consisting of high dose steroids and mycophenolate mofetil combined with or without the addition of BLM. MBC gene expression profiles were characterized with single-cell RNA and V(D)J sequencing (ScRNA-SEQ).

Results:

By employing HS flowcytometry, we established that the absolute increase in circulating MBC in SLE and LN patients was significant for patients who initiated BLM (Figure 1). The increase was observed in a broad range of MBC subsets (Unswitched, IgG1+, IgG2+, IgA1+, IgA2+) at 2 and 4 weeks following initiation of BLM treatment. This rise in MBC could hypothetically be attributed to either proliferation of blood MBC, BLM induced migration of tissue-resident MBCs or BLM related retention of tissue-destined MBC in the blood. ScRNA-SEQ analysis of cell cycle gene-expression was performed and established in both groups a non-proliferating phenotype [in approximately ~94%] of MBC post-treatment, including absence of MKI67 as active proliferation marker. Clonal diversity analysis comparing week 2 with baseline revealed an unexpected decrease of the largest MBC clones in BLM, whereas no change in clonality was observed with SOC alone. Together these data indicate that proliferation is unlikely to be responsible for the observed increase in MBC by BLM. Furthermore, a clear difference was found in gene-expression levels between both treatment groups: BLM was responsible for the upregulation of 72 vs 10 genes in SOC, likewise 162 vs 32 genes were downregulated. Most importantly, a significant downregulation of the migration genes SELL (CD62L), CCR7, ITGB1, RAC2 and ICAM2, were specifically seen in BLM treated patients. This may reflect disrupted lymphocyte trafficking, preventing MBCs from transmigrating from the blood into tissue owing to reduced migration molecules, or preventing MBCs from being retained at the tissue level owing to reduction in tissue adhesion proteins.

Conclusion:

The addition of BLM to SOC significantly increases MBCs in patients with SLE independently of proliferation, accompanied by a strong modulation of gene expression, including reduced expression of migration markers pointing towards disrupted lymphocyte trafficking. These data may have important implications for improving treatment strategies in patients with LN or severe SLE, as a deeper depletion of autoreactive MBCs could be established by adding B-cell-depleting therapy after the initiation of BLM.

Figure 1.

Change in pre-germinal center and memory B cell counts from baseline to week 4 of patients with SLE or LN treated with SOC (n=8) or SOC+BLM (n=11).

References:

[1]Arends EJ et al. Long-term effects of combined B cell immunomodulation with rituximab and belimumab in severe, refractory systemic lupus erythematosus: 2-year results. Nephrol Dial Transplant. 2020 Jun 27 gfaa117.

[2]Stohl W et al. Belimumab reduces autoantibodies, normalizes low complement levels, and reduces select B cell populations in patients with SLE. Arthritis Rheum. 2012;64(7):2328-2337.

[3]Blanco et al, Age-associated distribution of B and plasma cell subsets in peripheral blood - J Allergy Clin Immunol 2018 141 2208-2219.

Disclosure of Interests:

Eline J. Arends: None declared, Mihaela Zlei: None declared, Christopher M. Tipton: None declared, Zgjim Osmani: None declared, Sylvia Kamerling: None declared, Ton Rabelink: None declared, Ignacio Sanz: None declared, Jacques J.M. van Dongen Paid instructor for: BD Biosciences: Educational Services (fees for LUMC), Consultant of: BD Biosciences and Cytognos (fees for LUMC), Grant/research support from: GSK (flow cytometry studies for GSK BLISS-BELIEVE study NCT03312907), Cees van Kooten: None declared, Y.K. Onno Teng Consultant of: Aurinia provided financial compensation for consultancy, Grant/research support from: GSK provided belimumab for free for the Synbiose-2 clinical trial and provided an unrestricted grant to conduct the study.

An Asynchronous, Mobile Text-Based Platform (XatJove Anoia) for Providing Health Services to Teenagers: Protocol for a Quasiexperimental Study

Background

Due to the COVID-19 pandemic, it is more essential than ever to implement protective measures in primary care centers to ensure patients’ safety. This protocol describes a quasiexperimental study on the use of a mobile chat platform as a clinical consultation tool for adolescents and primary health care physicians.

Objective

The purpose of the quasiexperimental study is to demonstrate that the use of mobile phones and messaging apps increases the number of health consultations. The study will be performed as part of the Health and School program in the Anoia region.

Methods

The quasiexperimental study will compare the number of face-to-face consultations to the number of consultations conducted on XatJove Anoia, as part of the Health in Schools program in the Anoia region. The study will involve the use of a new communication platform (ie, XatJove Anoia) for health care professionals and adolescents, and data on the number of face-to-face consultations will be collected as part of the same program in another region. Data will be collected from secondary schools during the academic year 2020-2021. Statistical analyses will be performed on the data that users will enter in the registration form. These data will be collected by means of a questionnaire, which will be submitted once the questionnaire is closed. The questionnaire will consist of multiple-choice questions, which will allow numerical values to be assigned to various responses in order to carry out statistical analyses.

Results

The study is projected to start at the beginning of November 2020 and finish in June 2021, which is when data analysis is expected to start.

Conclusions

The results of the quasiexperimental study may assist in the development and planning of school health programs.

Trial Registration

ClinicalTrials.gov NCT04562350; https://clinicaltrials.gov/ct2/show/NCT04562350.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25062

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.

B lymphocytes in systemic lupus erythematosus: lessons from therapy targeting B cells

Systemic lupus erythematosus (SLE) is a complex disease characterizedby numerous autoantibodies and clinical involvement in multiple organ systems. Autoantibodies are usually present in serum for years before the onset of clinical disease. Autoimmunity begins with a limited number of autoantibodiesand evolves to become progressivelymore diverse. Eventually clinical disease ensues. The immunological events triggering the onset of clinical manifestations have not yet been defined. While undoubtedly T cells and dendritic cells appear to play major roles in SLE, a central role for B cells in the pathogenesis of this disease has been brought to the fore in the last few years by work performed both in mice and humans by multiple laboratories.As a result, there is little doubt about the importance of B cells in the development of SLE. Yet much remains to be learned about their role in the ongoing disease process and the merit of targeting B cells for the treatment of SLE. This article will review the role of B cells in human SLE as well as the currently available data on the treatment of SLE by depleting B cells with anti-CD20 (rituximab).

Effects of region of birth, educational level and age on late presentation among men who have sex with men newly diagnosed with HIV in a network of STI/HIV counselling and testing clinics in Spain

This paper analyses late presentation (LP) of HIV infection, and its determinants, among men who have sex with men (MSM) in Spain, newly diagnosed with HIV (2003-2011) in 15 sexually transmitted infection/HIV counselling and testing clinics. LP was defined as <350 CD4 cells/µL or AIDS. In total, 3,081 MSM were included (2,499 having CD4/AIDS); overall LP was 25.3%. LP was higher in men older than 34 years, those not previously HIV-tested (adjusted odds ratio (aOR):3.1; 95% confidence intervals (CI):2.3-4.2) , and those tested > 12 months before diagnosis (12-24 months (aOR:1.4; 95% CI:1.0-2.0); > 24 months (aOR:2.2; 95% CI:1.7-3.0)). LP was less likely in MSM reporting a known HIV-infected partner as infection source or symptoms compatible with acute retroviral syndrome. 'Region of birth' interacted with 'educational level' and 'steady partner as infection source': only African and Latin-American MSM with low educational level were more likely to present late; Latin-American men attributing their infection to steady partner, but no other MSM, had LP more frequently. In Spain, HIV testing among MSM should be promoted, especially those > 34 years old and migrants with low educational level. The current recommendation that MSM be tested at least once a year is appropriate.

Trends in HIV testing, prevalence among first-time testers, and incidence in most-at-risk populations in Spain: the EPI-VIH Study, 2000 to 2009

During 2000 to 2009, data on people undergoing HIV testing and on those newly diagnosed with HIV were collected in a network of 20 Spanish clinics specialising in sexually transmitted infections and/or HIV testing and counselling. The number of tests performed, overall and disaggregated by different variables, was obtained. HIV prevalence among first-time testers and HIV incidence among repeat testers were calculated. To evaluate trends, joinpoint regression models were fitted. In total, 236,939 HIV tests were performed for 165,745 individuals. Overall HIV prevalence among persons seeking HIV testing was 2.5% (95% CI: 2.4 to 2.6). Prevalence was highest in male sex workers who had sex with other men (19.0% (95% CI: 16.7 to 21.4)) and was lowest in female sex workers (0.8% (95% CI: 0.7 to 0.9)). Significant trends in prevalence were observed in men who have sex with men (MSM) (increasing) and heterosexual individuals (decreasing). The incidence analysis included 30,679 persons, 64,104 person-years (py) of follow-up and 642 seroconversions. The overall incidence rate (IR) was 1.0/100 py (95% CI: 0.9/100 to 1.1/100). Incidence was significantly higher in men and transgender females than in women (1.8/100 py (95% CI: 1.6 to 1.9), 1.2/100 py (95% CI: 0.5 to 2.8) and 0.1/100 py (95% CI: 0.09 to 0.2) respectively) and increased with age until 35–39 years. IRs in MSM and people who inject drugs were significantly greater than in heterosexual individuals (2.5/100 py (95% CI: 2.3 to 2.7), 1.6/100 py (95% CI: 1.1 to 2.2) and 0.1/100 py (95% CI: 0.09 to 0.2) respectively), and an upward trend was observed in MSM. Our results call for HIV prevention to be reinforced in MSM and transgender women in Spain.

Salivary anti-Ro60 and anti-Ro52 antibody profiles to diagnose Sjogren's Syndrome

Simple and non-invasive saliva-based diagnostics may be useful for the identification, understanding, and monitoring of autoimmune and infectious diseases. Previously, Luciferase Immunoprecipitation Systems (LIPS) were used for sensitive detection of patient serum autoantibodies in Sjögren's Syndrome (SjS), a chronic autoimmune disease affecting the salivary and lacrimal glands. Here we explored the ability of LIPS to diagnose SjS based on IgG autoantibodies in patient saliva. From LIPS testing, anti-Ro60 autoantibodies were detected in the saliva of 70% (19/27) of SjS patients with 96% specificity. Positive anti-Ro60 autoantibodies were also found in 70% of the matched serum samples (96% specificity). LIPS detected Ro52 autoantibodies in the saliva and serum of 67% of SjS patients with 100% specificity. Overall, the autoantibody titers in saliva were approximately 4000-fold lower by volume than serum, but still distinguished seropositive patients from controls. These results suggest that LIPS salivary-based testing for SjS autoantibodies is a practical alternative to serum and compatible with point-of-care testing.

HIV/STI co-infection among men who have sex with men in Spain

In Spain, neither the HIV nor the STI national surveillance systems collect information on HIV/STI co-infection. However, there are two networks based on HIV/STI clinics which gather this data. We describe HIV prevalence in men who have sex with men (MSM) diagnosed with infectious syphilis and/or gonorrhoea in 15 STI clinics; and concurrent diagnoses of STI in MSM newly diagnosed with HIV in 19 HIV/STI clinics. In total, 572 MSM were diagnosed with infectious syphilis and 580 with gonorrhoea during 2005-2007. HIV prevalence among syphilis and gonorrhoea cases was 29.8% and 15.2% respectively. In the multivariate analysis, HIV/syphilis co-infection was associated with being Latin American; having a history of STI; reporting exclusively anal intercourse; and having sex with casual or several types of partners. HIV and gonorrhoea co-infection was associated with age older than 45 years; having no education or only primary education completed; and having a history of STI. In total, 1,462 HIV infections were newly diagnosed among MSM during 2003-2007. Of these, 31.0% were diagnosed with other STI at the same time. Factors associated with STI co-infection among new HIV cases in MSM were being Latin American; and having sex with casual partners or with both steady and casual partners. In Spain, a considerable proportion of MSM are co-infected with HIV and STI.

The restorative effects of pulsed infrared light therapy on significant loss of peripheral protective sensation in patients with long-term type 1 and type 2 diabetes mellitus

Pulsed infrared light therapy (PILT) has been shown to increase peripheral sensation in diabetic patients with diabetic peripheral neuropathy (DPN). However, most studies last for very short periods, with the subjects receiving only 6-20 treatments. The purpose of this study was to evaluate the effectiveness of an eight-week course of PILT in reversing long-standing, profound DPN in patients with type 1 and type 2 diabetes. Twenty-two subjects with a diagnosis of type 1 (n=2) or type 2 (n=20) diabetes participated in the study. PILT was administered to one foot chosen at random with the other foot serving as a within-subject control (no treatment). Patients underwent 24 treatments (3 times/week, for eight weeks) for 30 min per treatment. Changes in peripheral protective sensation (PPS) were measured using Semmes-Weinstein monofilaments (SWM) ranging from 3.7 to 6.48. PILT improved PPS even in patients with long-standing chronic neuropathies whose initial pre-study sensation was not measurable with a 200-g SWM. PILT significantly improves PPS. While the exact mechanism of action is not understood, infrared light may improve peripheral neuropathies by improving foot perfusion by stimulating nitric oxide production.

Regulation of inherently autoreactive VH4-34 B cells in the maintenance of human B cell tolerance

The study of human B cell tolerance has been hampered by difficulties in identifying a sizable population of autoreactive B lymphocytes whose fate could be readily determined. Hypothesizing that B cells expressing intrinsically autoreactive antibodies encoded by the VH4-34 heavy chain gene (VH4-34 cells) represent such a population, we tracked VH4-34 cells in healthy individuals. Here, we show that naive VH4-34 cells are positively selected and mostly restricted to the follicular mantle zone. Subsequently, these cells are largely excluded from the germinal centers and underrepresented in the memory compartment. In healthy donors but not in patients with systemic lupus erythematosus (SLE), these cells are prevented from differentiating into antibody-producing plasma cells. This blockade can be overcome ex vivo using cultures of naive and memory VH4-34 cells in the presence of CD70, IL-2, and IL-10. VH4-34 cells may therefore represent an experimentally useful surrogate for autoantibody transgenes and should prove valuable in studying human B cell tolerance in a physiological, polyclonal environment. Our initial results suggest that both positive and negative selection processes participate in the maintenance of tolerance in autoreactive human B cells at multiple checkpoints throughout B cell differentiation and that at least some censoring mechanisms are faulty in SLE.

Delineation of the human systemic lupus erythematosus anti-Smith antibody response using phage-display combinatorial libraries

The anti-Smith (Sm) autoantibody response is highly specific for systemic lupus erythematosus and is predominantly targeted to the Sm-B/B' and -D1 polypeptides. In all animal species thus far studied, anti-Sm Abs initially recognize proline-rich epitopes in the carboxyl terminus of the Sm-B/B' protein and subsequently to multiple other epitopes in B/B' and D. The absence of appropriate mAbs has limited our understanding of the genetic and structural basis of this autoimmune response. Using phage-display technology and lymphocytes from a systemic lupus erythematosus patient we have generated the first and only panel of human IgG anti-Sm mAbs thus far available. These Abs reproduced to a remarkable extent the serological reactivity of the patient. Epitope mapping and genetic studies revealed that the anti-Sm response is produced by distinct B cell clones with restricted epitope reactivity. All of the Abs in our study were exclusively encoded by different members of the V(H)4 gene family. On the aggregate, our results demonstrate that combinatorial libraries can recapitulate the immune repertoire of peripheral blood B memory cells and that epitope spreading appears to occur through the sequential recruitment of nonclonally related autoreactive B cell clones.

Anticardiolipin antibodies and recurrent coronary events: a prospective study of 1150 patients. Thrombogenic Factors, and Recurrent Coronary Events Investigators

BACKGROUND

The association of anticardiolipin (aCL) antibodies with coronary artery disease has been shown in several studies but remains controversial. We evaluated the association of aCL and anti-beta(2)-glycoprotein I (abeta(2)GPI) antibodies with the risk of recurrent cardiac events in postinfarction patients.

METHODS AND RESULTS

The study population consisted of 1150 patients with acute myocardial infarction. Levels of IgG and IgM aCL and abeta(2)GPI antibodies were determined on sera collected before hospital discharge. There were 131 recurrent cardiac events (nonfatal myocardial infarctions or cardiac deaths) over a mean follow-up period of 24.6 months. Patients with elevated IgG aCL antibodies had a higher event rate than patients with low levels (P:=0.05). Multivariate Cox analysis after adjustment for relevant clinical covariates showed that elevated levels of IgG aCL (hazard ratio=1. 63; P:=0.01) and low levels of IgM aCL (hazard ratio of 1.76; P:=0. 02) antibodies contribute independent risks for recurrent cardiac events. Patients with elevated IgG aCL and low IgM aCL antibody levels had a 3-fold higher risk of recurrent cardiac events than patients with low IgG aCL and elevated IgM aCL antibody levels (P:<0. 001). There was no significant association of the abeta(2)GPI antibodies with recurrent cardiac events.

CONCLUSIONS

In postinfarction patients, elevated IgG aCL and low IgM aCL antibodies are independent risk factors for recurrent cardiac events. Patients with both elevated IgG aCL and low IgM aCL antibodies have the highest risk. These findings shed additional light on the mechanistic role of aCL antibodies in coronary artery disease in patients without autoimmune diseases.

Characterization of human anti-acetylcholine receptor monoclonal autoantibodies from the peripheral blood of a myasthenia gravis patient using combinatorial libraries

Myasthenia gravis (MG) is an autoimmune disease caused by autoantibodies against the nicotinic acetylcholine receptor (AChR). Using phage-display technology we have characterized the largest panel of anti-AChR monoclonal antibodies thus far isolated from a single patient. Despite having been isolated with either Torpedo AChR or a human peptide, the recombinant antibodies shared with the donor's serum the ability to recognize human AChR expressed in its native configuration on the surface of TE671 cells. Their specificity for the main immunogenic region (MIR) of the AChR was demonstrated using a synthetic peptide corresponding to the region 67-76 of the human AChR alpha subunit and by inhibition of a highly pathogenic rat anti-MIR monoclonal antibody (mAb35). This work demonstrates the value of combinatorial libraries in isolating pathogenic autoantibodies from peripheral blood lymphocytes. Future genetic, structural, and functional analyses of the monoclonal antibodies reported herein should enhance our understanding of the pathogenesis of MG.

NF-kappa B regulates VCAM-1 expression on fibroblast-like synoviocytes

Expression of VCAM-1 on synovial fibroblasts is a clinical hallmark of rheumatoid arthritis. The interaction of VCAM-1 and its integrin receptor very late Ag-4 is believed to be critically involved in the recruitment and retention of immune cells in the inflamed joints. To study the regulation of VCAM-1 in synovial fibroblasts, fibroblast-like synoviocytes (FLS) were isolated from the knee joints of normal mice and passaged repeatedly to obtain a homogeneous cell population. We have found that VCAM-1 is constitutively expressed on mouse FLS (mFLS) and that its surface expression is further increased after exposure to TNF-alpha. Nuclear translocation of transcription factor NF-kappa B including P50/P50 homodimer and P65/P50 heterodimer was activated by TNF-alpha treatment. In mFLS stably expressing a dominant-negative mutant of the inhibitory protein I-kappa B alpha- (mI-kappa B), which does not undergo proteolytic degradation, NF-kappa B remains in the cytosol and its activation in response to TNF-alpha is abolished. VCAM-1 protein expression after TNF-alpha stimulation was blocked in cells expressing the mI-kappa B. This effect is likely due to the loss of NF-kappa B-mediated transcription of VCAM-1, because the 5-fold increase in mRNA levels in response to TNF-alpha is absent in the mutant cells. To confirm these findings, we transduced mFLS with an adenoviral vector containing the mI-kappa B transgene. VCAM-1 expression was also blocked by mI-kappa B in this system, whereas cells transduced with a control adenoviral vector remained responsive to TNF-alpha. These results indicate that NF-kappa B mediates TNF-alpha-induced VCAM-1 expression on mFLS.

Ablation of tumor necrosis factor receptor type I (p55) alters oxygen-induced lung injury

Hyperoxic lung injury, believed to be mediated by reactive oxygen species, inflammatory cell activation, and release of cytotoxic cytokines, complicates the care of many critically ill patients. The cytokine tumor necrosis factor (TNF)-alpha is induced in lungs exposed to high concentrations of oxygen; however, its contribution to hyperoxia-induced lung injury remains unclear. Both TNF-alpha treatment and blockade with anti-TNF antibodies increased survival in mice exposed to hyperoxia. In the current study, to determine if pulmonary oxygen toxicity is dependent on either of the TNF receptors, type I (TNFR-I) or type II (TNFR-II), TNFR-I or TNFR-II gene-ablated [(-/-)] mice and wild-type control mice (WT; C57BL/6) were studied in >95% oxygen. There was no difference in average length of survival, although early survival was better for TNFR-I(-/-) mice than for either TNFR-II(-/-) or WT mice. At 48 h of hyperoxia, slightly more alveolar septal thickening and peribronchiolar and periarteriolar edema were detected in WT than in TNFR-I(-/-) lungs. By 84 h of oxygen exposure, TNFR-I(-/-) mice demonstrated greater alveolar debris, inflammation, and edema than WT mice. TNFR-I was necessary for induction of cytokine interleukin (IL)-1beta, IL-1 receptor antagonist, chemokine macrophage inflammatory protein (MIP)-1beta, MIP-2, interferon-gamma-induced protein-10 (IP-10), and monocyte chemoattractant protein (MCP)-1 mRNA in response to intratracheal administration of recombinant murine TNF-alpha. However, IL-1beta, IL-6, macrophage migration inhibitory factor, MIP-1alpha, MIP-2, and MCP-1 mRNAs were comparably induced by hyperoxia in TNFR-I(-/-) and WT lungs. In contrast, mRNA for manganese superoxide dismutase and intercellular adhesion molecule-1 were induced by hyperoxia only in WT mice. Differences in early survival and toxicity suggest that pulmonary oxygen toxicity is in part mediated by TNFR-I. However, induction of specific cytokine and chemokine mRNA and lethality in response to severe hyperoxia was independent of TNFR-I expression. The current study supports the prediction that therapeutic efforts to block TNF-alpha receptor function will not protect against pulmonary oxygen toxicity.

In vivo cell penetration and intracellular transport of anti-Sm and anti-La autoantibodies

Anti-nuclear autoantibodies (ANA) are the hallmark of systemic autoimmune diseases. Yet, the in vivo function of ANA remains controversial to a large extent due to the intracellular nature of their antigenic targets. It has been reported that a subset of autoantibodies can penetrate live cells and translocate into the subcellular compartments containing the corresponding antigens. The studies presented herein show that murine anti-Sm and anti-La monoclonal autoantibodies can also enter a variety of cell types from different animal species and that the cell penetration activity is not isotype-restricted. Interestingly, only mAb with cross-reactivity against double-stranded DNA did enter cells. Both these autoantibodies rapidly accumulate in the nucleus of viable cells but display different penetration kinetics. In co-localization experiments, monoclonal autoantibodies did not accumulate significantly within endocytic vesicles containing dextran, suggesting that they are internalized by mechanisms distinct from conventional receptor-mediated endocytosis. This report represents the first evidence that anti-La and anti-Sm autoantibodies are capable of entering live cells. Our observations support the notion that the phenomenon of intracellular autoantibodies may have a larger scope than previously reported and are consistent with a potential pathogenic role for ANA.

Empirical advantages of adeno associated viral vectors in vivo gene therapy for arthritis

OBJECTIVE

To evaluate the utility of the adeno associated viral (AAV) vector for gene delivery to joint cells in vivo and in vitro, and to assess its potential as a vector for arthritis gene therapy.

METHODS

A recombinant AAV (rAAV) vector expressing the bacterial beta-galactosidase (beta-gal) gene (rAAV-CMV-LacZ) was directly introduced into healthy-normal mouse knees, or arthritic knees in mice overexpressing tumor necrosis factor-alpha (hTNFalpha-Tg). Beta-gal expression levels were determined by immunohistochemistry and chemiluminescence. The transduction efficiency of this vector on primary fibroblast-like synoviocytes (FLS) in vitro was determined by FACS. The effects of UV and gamma-irradiation as well as TNF-alpha on transduction efficiency were determined using the same methods.

RESULTS

We found little evidence of rAAV transduction in the joint cells of healthy mice. Target gene expression was detected in all animals at Day 3, and peaked at Day 7 before returning to baseline levels 21 days after injection. In contrast, synoviocytes, articular chondrocytes, and meniscal cells of diseased mice were transduced by rAAV-CMV-LacZ in hTNFalpha-Tg animals. Transduction efficiencies correlated with joint damage, and target gene expression was up to 10-fold greater than that seen in the normal mice. In vitro, we found that rAAV transduction of FLS can be enhanced by pretreatment with UV or gamma-irradiation and TNF-alpha stimulation.

CONCLUSION

We find that rAAV vectors have several empirical advantages for in vivo gene therapy for arthritis: (1) rAAV preferentially transduces arthritic joint cells in vivo. (2) rAAV can transduce both FLS and chondrocytes in vivo. (3) rAAV transduction of FLS can be augmented by pretreatment with agents that induce DNA repair enzymes.

[In vitro immunosuppressive effect of low density lipoproteins]

BACKGROUND

Immune cells participate in the formation of atheromatous plate, however little is known about the effects of native or oxidatively modified lipoproteins on these cells.

AIM

To study the effects of lipoproteins on in vitro mononuclear cell proliferation.

MATERIAL AND METHODS

Peripheral blood mononuclear cells were obtained from 10 patients with type 2 diabetes mellitus (aged 52 +/- 9 years old with a disease duration of 8.2 +/- 5.7 years and a mean glycosilated hemoglobin of 9.3 +/- 2.2%) and 10 non diabetic healthy controls (aged 50.3 +/- 7.1 years old). These were stimulated with phytohemagglutinin (PHA) alone or in the presence of native LDLS, malondialdehyde modified LDLs or glycated LDLs. Proliferation was measured as 3H-thymidine incorporation and expressed as Stimulation Index (SI).

RESULTS

SI of patients and healthy subjects, after PHA stimulation were similar: (57.5 +/- 29.8 and 61.1 +/- 23.5) respectively LDLs did not induce proliferation in neither group. Native LDLs produced a 98% inhibition of PHA induced proliferation. Malondialdehyde modified and glycated LDLs caused a 50% inhibition. The suppressive effect was maintained when lipoproteins were incorporated to culture media 60 min prior or after PHA stimulation.

CONCLUSIONS

Lipoproteins inhibit in vitro PHA induced peripheral blood mononuclear cell proliferation both in diabetic and in non diabetic subjects.

Antimicrobial and antioxidant compounds in the nonvolatile fraction of expressed orange essential oil

Three permethoxylated flavones, dehydroabietic acid and linoleil monoglyceride were isolated from the nonvolatile residue of orange essential oil. All of them exhibited antifungal activity against phytopathogenic species and food contaminants. The isolated hexa- and heptamethoxy flavones exhibited important fungicidal activity against Geotrichum candidum, which is not inhibited by the commercial broadspectrum fungicide Benomyl (methyl-1-[butylcarbamoyl]-2-benzimidazolecarbamate); in addition, these compounds also exhibited effective antioxidant activities, similar to that shown by tert-butyl-4-hydroxyanisol, one of the most commonly used synthetic antioxidants; alpha-tocopherol, the most widely used natural antioxidant, was also isolated.

Tumor necrosis factor alpha receptor I is important for survival from Streptococcus pneumoniae infections

Tumor necrosis factor alpha (TNF-alpha) is important in resistance to various microorganisms and provides signals to the target cells through two different receptors, TNF-alpha receptor I (TNFRI) (p55 receptor) and TNFRII (p75 receptor). To delineate the significance of the two different signaling pathways in resisting infections with extracellular bacteria, we examined the resistance of mice to Streptococcus pneumoniae (serotype 6B). TNF-alpha needs to be present early in infections, since one injection of wild-type mice with anti-TNF-alpha leads to an increased susceptibility of these mice to S. pneumoniae. TNF-alpha signaling through the p55 receptor (but not the p75 receptor) is crucial in resisting S. pneumoniae infections, because intraperitoneal injection of 100 CFU/mouse killed p55-deficient mice by day 2 of infection, whereas 1,000,000 CFU/mouse was needed to kill half of the control mice. p55-deficient mice do not show evidence of a deficient acute-phase response. All three types of mice (p55 deficient, p75 deficient, and normal) showed comparable rises in the levels of two acute-phase proteins (serum amyloid P and C3) at 24, 48, and 72 h after the experimental infections, and all of the mice showed comparable influxes of neutrophils to the site of infection. Finally, it was demonstrated that p55-deficient mice can be protected from the lethal effects of S. pneumoniae infection by injection of antibodies specific for S. pneumoniae polysaccharide capsule.

[Cervical metastasis of choriocarcinoma]

Neck metastatic adenopathy involves to set off a protocol aiming to specify the growth's origin. Complete ENT-examination facing a hard, movable, laterocervical lump is compulsory. Lacking the primary next comes fine needle biopsy and if it's not clear enough a cervicotomy must be performed. We report the diagnosis, the treatment and the follow-up of a testicle choriocarcinoma case, diagnosed through neck biopsy. Perusal of the bibliography.

Human Ig heavy chain CDR3 regions in adult bone marrow pre-B cells display an adult phenotype of diversity: evidence for structural selection of DH amino acid sequences

Ig repertoires generated at various developmental stages differ markedly in diversity. It is well documented that Ig H chain genes in human fetal liver are limited with regard to N-regional diversity and use of diversity elements. It is unclear whether these characteristics persist in pre-B cell H chain genes of adult bone marrow. Using Ig H chain CDR3 fingerprinting and sequence analysis, we analyzed the diversity of Ig H chain third complementarity determining regions (HCDR3) in adult bone marrow pre-B and mature B lymphocytes. Pre-B cell HCDR3 sequences exhibited adult characteristics with respect to HCDR3 size, distribution of N regions and usage of diversity elements. This suggested that pre-B cells in adults are distinct from fetal B cell precursors with regard to Ig H chain diversification mechanisms. At the DNA sequence level, HCDR3 diversity in mature B cells was similar to that in pre-B cells. Pre-B HCDR3s, however, frequently contained a consecutive stretch of hydrophobic amino acids, which were rare in mature B cells. We propose that highly hydrophobic pre-B HCDR3s may be negatively selected on the basis of structural limitations imposed by the antigen binding site. At the same time, usage of hydrophilic HCDR3 sequences (thought to support HCDR3 loop formation) may be promoted by positive selection.

Gas generation and preconcentration coupled to gas phase molecular absorption spectrometry: a powerful tool for the simultaneous determination of analytes forming volatile compounds

Different methods for a simultaneous determination of several analytes forming volatile compounds at room temperature are described. The main steps of these methods are: continuous generation, collection in a cryogenic trap, revolatilization, measurement of the volatile compounds by Gas Phase Molecular Absorption Spectrometry and resolution by multi-wavelength methods. Several mixtures containing 2, 3 or 4 components have been studied: 1) elements forming covalent hydrides; 2) arsenic organometallic compounds forming volatile gases with a similar structure to arsine; and 3) sulphur species that can evolve volatile compounds. Under the optimum conditions obtained for each mixture, detection limits range from 0.8 ng/mL (dimethylarsinic acid) to 2 microg/mL (SCN(-)).

Molecular characterization of human Ig heavy chain DIR genes

Antibody VDJ recombination is ensured by evolutionarily conserved recombination signals (RS). The 12/23 rule postulates that only gene segments with asymmetrically spaced RS recombine with one another. Two unusually long D genes (170 bp) with irregular RS (DIR) have been reported in humans and have been postulated to participate actively in VDJ recombination, thus frequently contributing to the Ab heavy chain third hypervariable region (CDR3). However, the limited sequence information retained in the CDR3 along with significant sequence diversity has precluded an accurate assessment of the actual role and genomic diversity of DIR genes. Furthermore, DIR genes pose an interesting puzzle in terms of their precise mechanism of recombination because they possess multiple and imperfect RS, often located up to 30 bp away from the recombining fragment within the DIR coding region. Here we present conclusive evidence for the existence of additional human germ-line DIR genes and preliminary evidence that suggests the absence of DIR-like sequences in nonprimate animals. We also show that DIR genes are under the transcriptional control of VH-independent promoters and have the potential to encode a D mu protein of 105 amino acids. Finally, DIR genes seem at least in early fetal life to recombine preferentially through the conventional 3' RS.

Molecular characterization of human Ig heavy chain DIR genes

Antibody VDJ recombination is ensured by evolutionarily conserved recombination signals (RS). The 12/23 rule postulates that only gene segments with asymmetrically spaced RS recombine with one another. Two unusually long D genes (170 bp) with irregular RS (DIR) have been reported in humans and have been postulated to participate actively in VDJ recombination, thus frequently contributing to the Ab heavy chain third hypervariable region (CDR3). However, the limited sequence information retained in the CDR3 along with significant sequence diversity has precluded an accurate assessment of the actual role and genomic diversity of DIR genes. Furthermore, DIR genes pose an interesting puzzle in terms of their precise mechanism of recombination because they possess multiple and imperfect RS, often located up to 30 bp away from the recombining fragment within the DIR coding region. Here we present conclusive evidence for the existence of additional human germ-line DIR genes and preliminary evidence that suggests the absence of DIR-like sequences in nonprimate animals. We also show that DIR genes are under the transcriptional control of VH-independent promoters and have the potential to encode a D mu protein of 105 amino acids. Finally, DIR genes seem at least in early fetal life to recombine preferentially through the conventional 3' RS.

Cloning of a human IgM autoantibody bearing a cross-reactive idiotype in a lambda expression vector: a new approach to studying autoantibodies

The monoclonal antibody 4B4 is a human IgM,kappa which expresses a cross-reactive lupus-associated idiotype and has anti-Sm binding activity. We find that the VL nucleotide sequence of 4B4, like the 4B4 VH region, is encoded by unmutated germline genes. The 4B4 VH and VL were cloned into the ImmunoZap lambda expression vector to produce three recombinant immunoglobulin polypeptides. These recombinant polypeptides expressed, respectively, either the 4B4 VH or VL alone or a VH/VL heterodimer. ELISA showed that the VH/VL heterodimer retained anti-Sm antibody activity. The 4B4 idiotype was found predominantly on the VH. This report describes: (i) a method for producing recombinant immunoglobulin molecules from an IgM-secreting B cell line and (ii) the ability of recombinant antibody fragments expressed in Escherichia coli to retain the structural and antigenic properties of the native molecule.

Structure and specificities of anti-ganglioside autoantibodies associated with motor neuropathies

Autoantibodies that bind to GM1 ganglioside and asialo GM1 (GA1) have been implicated in the pathogenesis of motor neuropathies. To investigate the structure and specificity of these autoantibodies, peripheral blood B cells from patients with motor neuron diseases and from normal individuals were immortalized by EBV, and B cells secreting anti-GM1 or GA1 antibodies were cloned. We report an analysis of the structure and specificities of eight autoantibodies from patients with motor neuropathy, and two from normal individuals. Four antibodies were IgM, six were IgG, and all bound predominantly to GA1. The sequences of V domains of H and L chains were determined by a reverse transcription-polymerase chain reaction procedure. A variety of V genes were used to encode these antibodies: four VH1, two VH3, three VH4, one VH5, two V kappa I, two V kappa II, three V kappa III, and two V lambda II. Most V genes (13/19) exhibited less than 95% similarity to known germ-line genes, which suggests that somatic mutation was required to generate these autoantibodies, or that the relevant germ-line genes have not been identified. The average length of the H chain CDR3 was 16 amino acids, and in three antibodies this segment contained more than 20 amino acids. It was not possible to identify amino acid sequences that were encoded by germ-line D segments by conventional alignment of sequences. Partial analogies could be identified by introducing gaps, allowing mismatches and searching for D-D fusions and inversions. These results indicate that anti-GA1 antibodies can be encoded by a variety of VH-VL pairs, that the antibodies exhibit extensive somatic mutation, and that the CDR3 segments are generated by a number of nonconventional mechanisms.

Structure and specificities of anti-ganglioside autoantibodies associated with motor neuropathies

Autoantibodies that bind to GM1 ganglioside and asialo GM1 (GA1) have been implicated in the pathogenesis of motor neuropathies. To investigate the structure and specificity of these autoantibodies, peripheral blood B cells from patients with motor neuron diseases and from normal individuals were immortalized by EBV, and B cells secreting anti-GM1 or GA1 antibodies were cloned. We report an analysis of the structure and specificities of eight autoantibodies from patients with motor neuropathy, and two from normal individuals. Four antibodies were IgM, six were IgG, and all bound predominantly to GA1. The sequences of V domains of H and L chains were determined by a reverse transcription-polymerase chain reaction procedure. A variety of V genes were used to encode these antibodies: four VH1, two VH3, three VH4, one VH5, two V kappa I, two V kappa II, three V kappa III, and two V lambda II. Most V genes (13/19) exhibited less than 95% similarity to known germ-line genes, which suggests that somatic mutation was required to generate these autoantibodies, or that the relevant germ-line genes have not been identified. The average length of the H chain CDR3 was 16 amino acids, and in three antibodies this segment contained more than 20 amino acids. It was not possible to identify amino acid sequences that were encoded by germ-line D segments by conventional alignment of sequences. Partial analogies could be identified by introducing gaps, allowing mismatches and searching for D-D fusions and inversions. These results indicate that anti-GA1 antibodies can be encoded by a variety of VH-VL pairs, that the antibodies exhibit extensive somatic mutation, and that the CDR3 segments are generated by a number of nonconventional mechanisms.