Practice patterns in longitudinal lupus care provision: patient and physician perspectives

Background/purpose

To plan a quality improvement project, we need to understand the practice patterns of physicians. We undertook an online survey of systemic lupus erythematosus (SLE) patients and physicians providing care to SLE patients to determine the patterns of medical care provided to SLE patients.

Materials and methods

Two self-report surveys were developed. A 12-item survey for the patients and a 13-item survey for physicians enquired about longitudinal care for SLE. Surveys were administered online to physicians providing care to SLE patients, and to patients who self-identified as having SLE, through the Lupus Society of Illinois. Patient and physician data were analyzed for physician practice patterns for SLE care, using chi square tests and t tests. A P value of 0.05 or less was considered significant on two-tailed tests.

Results

A total of 283 patients completed the survey. Mean (SD) age and disease duration of patients were 45.9 (13.2) and 12.7 (9.7) years. Half of the participants were being seen at 3–4-month intervals. More than 70% of patients reported being tested for antinuclear antibody (ANA), and 20–30% anti-ENA antibody and Sjögren’s (SSA/SSB) antibodies, respectively, at each follow-up visit. Eighty-six rheumatologists completed the surveys. Mean (SD) age was 55 (12) years and 56% were men. More than half (54%) provided care only in a private practice setting. More than 80% of physicians reported seeing their SLE patients at 3–4-month interval. Only 2% reported performing ANA tests at each visit, while 4–5% performed anti-ENA and anti-SSA/SSB antibody tests at each visit for their SLE patients. More than 75% of physicians in private practice also ordered sedimentation rate at each visit for their SLE patients.

Conclusions

Unnecessary laboratory investigations may be being ordered routinely for patients at every visit. These results indicate a need for physician education on indications and utility of some of the laboratory tests such as ANA.

Searching for Dark Matter Annihilation from Milky Way Dwarf Spheroidal Galaxies with Six Years of Fermi Large Area Telescope Data

The dwarf spheroidal satellite galaxies (dSphs) of the Milky Way are some of the most dark matter (DM) dominated objects known. We report on γ-ray observations of Milky Way dSphs based on six years of Fermi Large Area Telescope data processed with the new Pass8 event-level analysis. None of the dSphs are significantly detected in γ rays, and we present upper limits on the DM annihilation cross section from a combined analysis of 15 dSphs. These constraints are among the strongest and most robust to date and lie below the canonical thermal relic cross section for DM of mass ≲100  GeV annihilating via quark and τ-lepton channels.

In silico and in vivo analysis of binding affinity of estrogens with estrogen receptor alpha in Channa punctatus (Bloch)

In the present study, potential interaction between natural estrogens i.e., estrone (E(1)), estradiol (E(2)) and estriol (E(3)) with human estrogen receptor (hER) was seen by in silico study. Molecular docking studies were carried out using Glide and ligand docking program. The binding affinity, assessed by Glide score, indicates stronger interaction of E(3) with hER followed by E(2) and E(1). Real-time PCR analysis of vga and vgb expressions, in the liver of different groups of Channa punctatus injected with the three natural estrogens, supported the docking analysis and indicated E(3) to be the most potent estrogen in inducing vga and vgb expressions followed by E(2) and E(1). This study lays the groundwork for studying interactions of various estrogenic substances with different estrogen receptors and to assess estrogenicity of various chemicals which are being released into the environment by employing molecular docking technique.

Characterization of incomplete vitellogenin (VgC) in the Indian freshwater murrel, Channa punctatus (Bloch)

A novel incomplete vitellogenin (VgC) was purified from the plasma of estradiol-treated male murrel, Channa punctatus, by gel filtration chromatography. The native mass of VgC protein was 180 kDa, and it resolved as a single peptide of 100 kDa on SDS-PAGE. The peptide on subjecting to matrix-assisted laser desorption/ionization-time of flight produced a peptide mass fingerprint. On tandem mass spectrometry, some of these peptides showed mass to charge (m/z) ratio and amino acid sequence similarity with VgC peptides of other teleosts. Phylogenetic analysis revealed a similarity of murrel VgC with fish species of the order Perciformes. Semi-quantitative RT-PCR assay was developed to study expression of vgc gene at variable levels of estradiol exposure. Presence of VgC in males indicates that fish has been exposed to estrogens; hence, it can be used as a biomarker for estrogenic exposure.

Purification, characterization and expression of two vitellogenins in the Indian freshwater murrel Channa punctatus

The present study was undertaken to characterize different vitellogenins in Channa punctatus. Protein purification by gel chromatography followed by fast protein liquid chromatography (FPLC) revealed existence of two different Vg forms. Liquid chromatography tandem mass spectrophotometry (LC-MS/MS) suggested the existence of Vga and Vgb. Cloning of partial sequences of vga and vgb mRNA and phylogenetic analysis substantiated the existence of two vitellogenins. Real time PCR for vga and vgb genes from liver of estradiol-17β (E2) treated fish reveals difference in expression levels of transcripts of these two genes. vgb is expressed at lower dose of estradiol suggesting a higher sensitivity to estradiol. The present study thus proposes different regulatory control for the expression of these two genes and vgb as a superior biomarker than vga to assess exposure of C. punctatus to environmental estrogens.

Isolation, purification and characterization of the egg-yolk proteins from the oocytes of the indian freshwater murrel, Channa punctatus (Bloch)

In oviparous organisms, yolk accumulation in the oocytes is critical and indispensable for the development of the newly hatched young ones. In fish and many other oviparous vertebrates, the major constituents of the egg-yolk are synthesized as a precursor in the liver. The precursor is transported to the oocyte for uptake and cleaved into major yolk proteins lipovitellin, phosvitin and beta'-components. The eggs of Channa punctatus are pelagic, have large oil globule and exceptionally high lipid content. Lipovitellin was isolated by single step gel filtration chromatography on Sepharose 6B. Purified native lipovitellin showed immunological reactivity with vitellogenin antiserum. Phosvitin isolated by phenol extraction method could not be visualized with routine protein staining methods, whereas incorporation of trivalent ions in the coomassie brilliant blue stained phosvitin. It was characterized by in vivo labeling of egg-yolk proteins with 32P. The molecular mass of murrel phosvitin was less than 14,000 kDa.

Vitellogenin genes in fish: differential expression on exposure to estradiol

Three types of vitellogenins (Vgs) namely vitellogenin A (VgA), vitellogenin B (VgB) and vitellogenin C (VgC) have been identified in fishes. The existence of VgA and VgB is reported in the Indian freshwater murrel Channa punctatus. Gene-specific primers were designed using available nucleotide sequences in National Centre for Biotechnology Information (NCBI), for amplification of VgA and VgB cDNA. Differential processing of Vgs is evident in many fishes. Adult male murrel expressed both the VgA and VgB genes when estradiol-17β (E(2)) is injected in vivo and Vg levels in blood quantified by Enzyme linked immunosorbent assay (ELISA) showed a dose-related response in such treatments. Cultured hepatocytes on treatment with E(2), however, expressed only VgB as detected by RT-PCR, suggesting different regulatory mechanism for the VgA and VgB genes.

Testosterone administration to adult rats differentially modulates androgen and oestrogen receptor-α expression in reproductive organs and pituitary

Regulation of androgen receptor (AR) and oestrogen receptor α (ERα) expression has direct bearing on the physiology of male reproductive organs. With the help of three independent tools of immunohistochemistry, western blotting and RT-PCR, AR and ER α receptor expression was examined in the testis, epididymis, prostate, seminal vesicle and pituitary of adult rats following testosterone enanthate (TE, 3 mg/100 μl of olive oil/rat per week) intervention for 15 and 30 days. TE administration reduced AR immunoexpression which coincided well with the decline in the receptor protein and transcript levels. In contrast, ERα was found overexpressed in all the organs. While weights of testis and epididymis decreased significantly, those of prostate, seminal vesicle and pituitary demonstrated an upward trend. Spermatogenesis was adversely affected with decline in number of germ cells per tubule and increased prevalence of germ cell apoptosis. Increase in serum and decrease in intra-testicular levels of testosterone were found significant (P < 0.001) in both 15 and 30 days treatment groups. Serum follicle stimulating hormone declined significantly (P < 0.001) at the end of 30 days treatment. Taken together, the above findings indicate that the testosterone intervention differentially modulates, AR ERα expression, which is associated with hypospermatogenesis and increased germ cell apoptosis.

Relative potencies of natural estrogens on vitellogenin and choriogenin levels in the Indian freshwater spotted snakehead, Channa punctata: in vivo and in vitro studies

The relative efficacies of three natural estrogens viz., estrone (E(1)), estradiol-17beta (E(2)) and estriol (E(3)) to induce synthesis of vitellogenin (Vg) and choriogenin (Chg) were assessed in primary hepatocyte cultures of the Indian freshwater spotted snakehead, Channa punctata. Hepatocytes were isolated from the spotted snakehead liver by a non-enzymatic protocol. Optimum culture conditions were standardized for ensuring their viability and functioning. Isolated hepatocytes were cultured for 48 h for monolayer formation and then exposed to various concentrations (0.001-10 microM) of the three estrogens. Competitive homologous ELISAs, developed and validated for spotted snakehead Vg and Chg were employed to determine the amounts of these two proteins secreted into the culture medium after 48 h of incubation. The results reveal that although all the three estrogens were effective in inducing the production of Vg and Chg in a dose-dependent manner, there were differences in their relative potencies. Of three estrogens, E(1) was the least potent and could induce synthesis of Vg and Chg only at a minimum concentration of 0.5 microM; whereas significant levels of both the proteins were quantified in culture medium by exposing the hepatocytes to E(2) or E(3) even at a concentration of 0.001 microM. All three estrogens were effective in inducing synthesis of Vg and Chg in vivo also. These results suggest the possibility of employing the above in vitro experimental design to monitor the presence of estrogens/estrogen-like chemicals in natural waters, which could interfere with the estrogen receptor system of fish. This study further points to the possibility of using Chg, in addition to Vg, as a parameter for screening various chemicals for their estrogenic activity.

hCG treatment raises H2O2 levels and induces germ cell apoptosis in rat testis

The clinical significance of exogenous hCG treatment is to stimulate steroidogenesis and spermatogenesis in the testis. However, the pathogenesis of detrimental effects on the testis arising out of chronic hCG treatment is yet to be clearly ascertained. In the present study we have shown that hCG treatment (100 IU/day) to rats for 30 days raises testicular oxidative stress leading to germ cell apoptosis and impairment of spermatogenesis. The treatment raises testicular H(2)O(2) levels along with increase in lipid peroxidation and concomitant decrease in the enzymatic antioxidant activities like superoxide dismutase, catalase and glutathione-s-transferase. The rise in the number of apoptotic germ cells was associated with up regulation of Fas protein expression and caspase-3 activity in the testis. However, serum testosterone which was elevated by 15 days of hCG treatment declined to pretreatment levels by 30 days. No significant alteration in serum gonadotropins was observed. The above findings indicate that the pathogenesis of deleterious effects following chronic hCG treatment is due to increase in testicular oxidative stress with high H(2)O(2) availability leading to apoptosis among germ cells.

H2O2 at physiological concentrations modulates Leydig cell function inducing oxidative stress and apoptosis

H(2)O(2) is one of the active reactive oxygen species secreted by macrophages that are seen closely aligned with Leydig cells in the testicular interstitium. The present study was initiated to investigate the role of H(2)O(2) on Leydig cell function in vitro at physiological concentrations. Significant decrease in both testosterone production (p < 0.05) and 3 beta-hydroxysteroid dehydrogenase activity (p < 0.05) in adult Leydig cells were observed even with H(2)O(2) at low concentrations (30 - 50 microM). H(2)O(2) exposure increased oxidative stress in Leydig cells with the rise in lipid peroxidation and fall in the activities of the antioxidant enzymes; superoxide dismutase (SOD), catalase (CAT) & glutathione-s-transferase (GST). There was also a marginal increase (approximately 8%) in cell apoptosis accompanied by rise in FasL expression and caspase-3 activation. The above findings indicate that H(2)O(2) as a bio-molecule modulates Leydig cell function at or below physiological concentrations through a variety of actions like decrease in steroidogenic enzyme activity and increase in oxidative stress and apoptosis.

Antiretroviral agents restore Mycobacterium-specific T-cell immune responses and facilitate controlling a fatal tuberculosis-like disease in Macaques coinfected with simian immunodeficiency virus and Mycobacterium bovis BCG

The contribution of immune reconstitution following antiretroviral treatment to the prevention or treatment of human immunodeficiency virus-related primary or reactivation tuberculosis remains unknown. Macaque models of simian immunodeficiency virus-Mycobacterium bovis BCG (SIV/BCG) coinfection were employed to determine the extent to which anti-Mycobacterium tuberculosis immunity can be restored by antiretroviral therapy. Both SIV-infected macaques with active BCG reinfection and naive animals with simultaneous SIV/BCG coinfection were evaluated. The suppression of SIV replication by antiretroviral treatment resulted in control of the active BCG infection and blocked development of the fatal SIV-related tuberculosis-like disease. The resolution of this disease coincided with the restoration of BCG purified protein derivative (PPD)-specific T-cell immune responses. In contrast, macaques similarly coinfected with SIV/BCG but not receiving antiretroviral therapy had depressed PPD-specific primary and memory T-cell immune responses and died from tuberculosis-like disease. These results provide in vivo evidence that the restoration of anti-mycobacterial immunity by antiretroviral agents can improve the clinical outcome of an AIDS virus-related tuberculosis-like disease.

Purification of vitellogenin from the plasma of Indian freshwater murrel, Channa punctatus (Bloch) by different methods: a comparative study

Plasma from estrogenized, [32P] NaH2PO4-injected murrel, Channa punctatus was collected in the presence of proteolytic inhibitors and subjected to different separation procedures singly or in combination, viz., gel filtration chromatography on Ultrogel AcA 34, ion-exchange chromatography on DEAE sephacel, or selective precipitation with dimethylformamide or with Mg2+: EDTA in order to isolate vitellogenin from other plasma proteins. The results show that chromatography on Ultrogel or DEAE sephacel yields intact vitellogenin whereas prior precipitation with DMF or with Mg2+: EDTA results in either co-precipitation of other plasma proteins or in the cleavage of phosvitin-like material from the native vitellogenin molecule.

Internal disc disruption and low back pain

Internal disc disruption is a common cause of disabling low back pain in a substantial number of young, healthy adults. Crock described this painful entity and reported annular fissures that distort the internal architecture of the disc; Externally the disc appears relatively intact and undeformed. A clinical diagnosis of internal disc disruption, in absence of objective clinical findings, is extremely difficult. The only convincing means to establish the diagnosis is provocation discography. Unfortunately, this procedure is controversial, making the existence of internal disc disruption suspect. Recent studies indicate the existence of a biochemical/ biomechanical model of discogenic pain, which explains the disabling low back pain in some subjects with no objective evidence of nerve-root compromise. However, a reluctance to acknowledge internal disc disruption as a valid clinical entity delays diagnosis and treatment. Failure to identify and treat this entity early and aggressively results in longterm disability, thereby perpetuating the enigma of chronic low back pain.

The disruption of macaque CD4+ T-cell repertoires during the early simian immunodeficiency virus infection

T-cell receptor (TCR) complementarily determining region 3 (CDR3) spetratyping analysis was employed to assess the ability of an AIDS virus to disrupt CD4 + T-cell repertoires during the primary infection. Rhesus and pig-tailed macaques infected with simian immunodeficiency virus (SIV)mac 251 and SIVsmmFGb, respectively, were evaluated. Following SIV infection, the macaques exhibited an apparent decline of CD4 + peripheral blood lymphocyte (PBL) counts, which was associated with a change in CDR3 profiles from multiple-length distribution to one- or two-length dominance in the selected TCR Vbeta-expressing CD4 + PBL subpopulations. Molecular analysis of the perturbed cell subpopulations suggested that the CD4 + T cells bearing the dominant CDR3 length were clonally expanded. These results indicate that SIV infection can induce a disruption of macaque CD4 + T-cell repertoires during the primary infection. The finding in this study, therefore, suggests that the virus-induced clonal dominance can contribute to the disruption of CD4 + T-cell repertoires.

Beyond Ashworth. Electrophysiologic quantification of spasticity

Spasticity is a hallmark of upper motor neuron lesion, which is easily identified but is difficult to quantify and treat. The Ashworth scale lacks reliability. Available biomechanical and electrophysiologic studies offer a more reliable measure of spastic hypertonia but have limited clinical utility. A uniformly acceptable, reliable, and practical measure of spasticity continues to elude the clinician. This chapter reviews the basic neuroanatomy and physiology of the stretch reflex and the pathophysiology of the spasticity. Current biomechanical and electrophysiological techniques are used to quantify spasticity.

Risk of recurrent seizures after a primary human herpesvirus 6-induced febrile seizure

OBJECTIVE

To test the hypothesis that children experiencing first febrile seizures caused by human herpesvirus 6 (HHV-6) have an increased risk for recurrent seizures when compared with children experiencing first febrile seizures attributed to other illnesses.

DESIGN AND PARTICIPANTS

Descriptive prospective study of 36 HHV-6 culture-positive children and a matched subgroup of 86 HHV-6 culture-negative children, all of whom had their first febrile seizures evaluated in a tertiary care emergency department and were followed for at least 12 months, with an average follow-up of 35.7 months.

PRIMARY OUTCOME MEASURE

The recurrence of seizures among HHV-6 culture-positive and HHV-6 culture-negative children with no known previous neurologic deficits.

RESULTS

A decreased incidence of recurrent seizures occurred in children whose first febrile seizures were caused by HHV-6. Twenty percent of HHV-6 culture-positive children and 40% of HHV-6 culture-negative children (P < 0.038) experienced a recurrent seizure within 1 year of their first febrile seizure. The mean time to recurrence within 12 months was 8.6 months for children with HHV-6 infection and 3.8 months (P < 0.001) for children without HHV-6 infection. Most recurrent seizures occurred within 12 months of a first febrile seizure for both HHV-6-positive and HHV-6-negative children (88 and 91%).

CONCLUSIONS

Children who had their first febrile seizures caused by primary HHV-6 infection did not demonstrate an increased risk for recurrent seizures when compared with children whose first febrile seizures were from other etiologies.

Three-dimensional reconstruction of anomalous beige mouse macrophage lysosomes

Cells of the beige mouse, the murine counterpart of the Chediak-Higashi Syndrome, contain enlarged anomalous lysosomes. The three-dimensional structure of these lysosomes from peritoneal macrophage was ascertained by study of electron micrographs taken in a series of serial sections combined with computer-assisted analysis. The most common basic structural units identified were biconcave discs and hollow cup/ovoid-shaped structures. Other more bizarre forms were represented by the fusion of these basic lysosomal variants. Anomalous lysosomal forms were found in both beige resident and exudate peritoneal macrophage. A similar study of lysosomes in animals not carrying the beige mutation revealed the presence of smaller but structurally similar forms of the basic lysosomal variants. This latter finding indicates that the presence of lysosomal variants per se in the beige animal is not a finding unique to these animals but rather that their distinctiveness derives from their increased size and propensity to undergo fusion with each other. The usefulness of computer-assisted three-dimensional reconstruction is demonstrated.

Qualitative and quantitative differences between resident peritoneal mononuclear phagocytes of beige and control mice

A qualitative and quantitative comparison of resident peritoneal macrophages (RPM) from beige (C57BL6Jbg/bg), (bg), and control black (C57BL/6J), (BL), mice has been made. Giant anomalous lysosomes as described for other leukocytes are inconsistently demonstrable. The principal morphological expression of the bg phenotype in RPM is the presence of elongated dumbbell-shaped, horseshoe-shaped, and ring-formed cytoplasmic lysosomes demonstrable by electron microscopy. Detailed analysis indicates that these are probably variations of the same basic structure, a deformed biconcave disc with differences in form resulting from their being cut in various planes of section. Additional structural complexity results from fusion between adjacent lysosomes. Thus the distinctive lysosomes of bg mouse RPM are not totally analogous to those structures described in other cell types. A morphometric analysis of control RPM compared to those from bg animals shows a significant decrease in the lysosomal volume proportion from 5.8% to 5.0% (P less than 0.02) with a corresponding increase in the mitochondrial volume proportion in cells from bg animals (P less than 0.05). There are no differences between bg and controls in regard to cellular profile areas, nuclear profile areas, nuclear volume proportions, and the volume to surface ratios of either the average cell or nucleus. This study represents the first compilation by morphometric methods of total granule content in the bg animal and demonstrates the ability of these techniques to detect significant quantitative changes in cells as structurally complex as mononuclear phagocytes.

Changes in content and cAMP-dependent phosphorylation of specific proteins in granulosa cells of preantral and preovulatory ovarian follicles and in corpora lutea

The responsiveness of granulosa cells to the gonadotropins and cAMP increases as ovarian follicles mature. To determine if this change in response might be related to either the content or cAMP-dependent phosphorylation of specific proteins, we labeled proteins in 30,000 X g supernatant fractions (cytosol) with [gamma-32P] ATP in the presence or absence of cAMP. Using two-dimensional gel electrophoresis, we observed that granulosa cells of preantral follicles exhibited low amounts of cAMP-dependent phosphorylation of two proteins with apparent molecular weights of 54,000-56,000 and 43,000. Using [32P]8-N3cAMP and photoaffinity labeling procedures, the Mr = 54,000-56,000 protein was identified as RII, the regulatory subunit of type II protein kinase. Polychromatic silver staining, as well as the photoaffinity labeling, revealed that RII exists in three forms, each of which was also labeled by [gamma-32P] ATP. Based on the relative isoelectric points and specific silver staining of highly purified actin and phosphorylated actin, the Mr = 43,000 protein has been provisionally identified as actin. Five proteins (Mr = 37,500, 27,500, 22,500, 19,000, and 15,000), in addition to RII and actin, were phosphorylated in cytosol of granulosa cells from preovulatory follicles. By adding increasing concentrations of exogenous catalytic subunit to the cytosols, we demonstrated that the content, as well as the phosphorylation of these proteins, was increased selectively in granulosa cells of antral follicles. By using hypophysectomized rats, we demonstrated that these five proteins are induced by follitropin (FSH). Because they were not present in cytosols of thecal cells or corpora lutea, they appear to be specific markers for granulosa cells. The content and phosphorylation of RII was also dramatically increased in cytosols of granulosa cells from antral follicles, whereas that of actin remained unchanged. These observations indicate that granulosa cell differentiation involves regulation by FSH of specific proteins which are substrates for cAMP-dependent protein kinase. Thus, FSH and cAMP appear to regulate the intracellular content and phosphorylation of a cAMP response system in granulosa cells. The extent to which RII and the five specific phosphoproteins themselves regulate granulosa cell responsiveness remains to be determined.

Epidemiological and clinical patterns of genital lesions

A 5-year study of 668 patients with genital lesions revealed that teenagers and those in the age group of 20 to 40 are most vunerable. The poor, the uneducated and unmarried persons are at high risk. Chancroid and syphilis are the majority of cases. Inguinal bubo, herpes pregenitalis, condylomata acuminata, erosive balanitis and traumatic ulcers were seen less frequently. Most of the genital lesions had the classic clinical features. The findings of this study suggest that the pattern of genital lesions is showing borderline changes.