There is no doubt that the arrival and licensing of two tumour necrosis factor (TNF)-blocking drugs—infliximab and etanercept—for the treatment of ankylosing spondylitis (AS) represents the first major advance in the treatment of this condition since the advocacy of exercises and the introduction of phenylbutazone. These agents have also been shown unequivocally to be effective in a proportion of patients with psoriatic arthritis (PsA), comparable to their effect in rheumatoid arthritis (RA), and anecdotal reports also suggest benefits for patients with enteropathic arthritis, persistent reactive arthritis (ReA) and undifferentiated spondyloarthropathy (SpA). But, as with RA, the availability of these agents places a huge responsibility upon rheumatologists, individually and collectively, to negotiate the poorly charted waters of assessment of disease outcomes, known and potential drug toxicity and potentially massive cost. Moreover, all parties to the negotiation are signed up to the provision of such treatment according to criteria that are wise, transparent and fair. For the SpAs, the opportunities provided by TNFblockade come not a moment too soon but at a difficult time. In recent years huge expertise has developed in the assessment of RA and the development of suitable instruments for that purpose. In contrast, the SpAs have received much less clinical trial attention and clinicians are less well equipped to make objective assessments. Indeed, until the last few years few useful measures were available, especially for the assessment of spinal disease. Fortunately, several groups, notably that at Bath, UK, have developed and validated instruments for measuring such attributes as disease activity, function and pain in AS and more recently an international group of rheumatologists interested in AS have formed the Assessments in Ankylosing Spondylitis (ASAS) working group to attempt to reach consensus over treatment issues which cannot presently be governed by objective criteria such as the presence or absence of joint erosions. Thus, just in the nick of time, a basis has been laid on which to build a framework within which TNFblockade and other biological therapies can reasonably be used in the treatment of SpAs. Unfortunately, at present much of that framework relies heavily on subjective measures, with very limited objectivity. But the need for guidance is now, as our patients need treatment now. Such guidance as emerges must therefore be seen as provisional and requiring regular revision year on year.
Objectives. The aim of this study was to evaluate the effects of moderately intensive pool exercise therapy on patients with rheumatoid arthritis (RA).Methods. Forty-six patients with chronic RA were randomly assigned to a treatment group and a control group. The treatment group (n = 20) exercised in a temperate pool twice a week for 12 weeks. The control group (n = 23) continued with their previous activities. Aerobic capacity, measured by means of a submaximum bicycle test, and the physical component of the SF-36 were chosen as the primary outcome measures. Two tests of muscle endurance were chosen as the secondary outcome measure. Additional functional tests and instruments were included.Results. No significant differences between the groups were found for the primary outcome measures. Significant improvements in the following aspects of muscular function (P < 0.05) were found in the treatment group when their performance was compared with that of the control group: isometric shoulder endurance, grip force, dynamic endurance of lower extremities (chair test) and muscle function of lower extremities. Significant improvements were also found for vitality (SF-36) compared with the control group. The improvements in the training group were maintained for 3 months.Conclusions. Pool exercise therapy of moderate intensity significantly improved muscle endurance in the upper and lower extremities in patients with RA, while no impact on aerobic capacity was found. However, the study population was small and there is a need for further studies with larger populations.
OBJECTIVES:Leucocyte infiltration is the hallmark of vasculitis, chemokines being mainly responsible for leucocyte migration into inflamed tissues. The objective was to evaluate the local expression of chemokines and chemokine receptors in biopsies of patients with giant cell arteritis (GCA) compared with arteries from patients with polymyalgia rheumatica (PMR). We studied the expression of CCR5, CXCR3 and that of the Duffy antigen/receptor of chemokine (DARC), a chemokine internalizing receptor (interceptor), in parallel to the expression of the CCR5 ligand RANTES/CCL5.METHODS:Paraffin-embedded tissue sections from six patients with GCA and five patients with PMR were available for immunohistological analysis of chemokine receptor expression. RANTES/CCL5 mRNA was detected in tissue sections by in situ hybridization.RESULTS:In patients with biopsy-proven giant cell arteritis, CCR5 and CXCR3 were highly expressed by infiltrating leucocytes in involved tissue sections. Predominant clustering of CCR5+ and CXCR3+ leucocytes was found in the adventitia and was co-localized with the expression of CCL5/RANTES mRNA. Interestingly, we found marked expression of DARC on adventitial high endothelial venules in vasculitis lesions of patients with GCA, while in arteries from patients with PMR DARC was only expressed on a low number of vessels with flat lining endothelium.CONCLUSIONS:The co-localization of infiltrating CCR5+ and CXCR3+ leucocytes together with CCL5/RANTES and DARC in vasculitis lesions suggests a role for these chemokine receptors in leucocyte infiltration, possibly supported by DARC-mediated vascular presentation of chemokines.
of patients with a flare over the median period of follow-up (27 months), 7% per year.All the patients who had a flare were female (100%) reflecting the cohort generally [48/50 (96%) of those without were also female].They were slightly younger with a median age of 50.0 yr (range 39-58 yr) compared with 58.5 yr (range 30-84 yr) in those without a flare (P ¼ 0.018).Although the median disease duration (at 31 December 2001) in those with and without a flare was similar [4.0 yr (range 1-15 yr) and 4.5 yr (range 0-31 yr)], the median period of follow-up within the clinic was longer for the flare group [38 months (range 11-58 months) compared with 25 months (range 1-60 months); P ¼ 0.017] (i.e. the detection of flares may be dependent on the duration of follow-up).There was no difference in the frequencies of anti-Ro/La antibody (89% compared with 72%) or rheumatoid factor (RF) positivity (78% compared with 72%), whereas the flare group were slightly more likely to be antinuclear antibody (ANA) positive [8/9 (89%)] compared with those without [26/50 (52%); P ¼ 0.039].The proportion of patients in this cohort with fibromyalgia was under 5% [4].Table 1 summarizes the clinical features of the flares.These were predominantly musculoskeletal and consisted of: increased fatigue/malaise, 7/12 (58%); polyarthritis, 7/12 (58%); polyarthralgia, 7/12 (58%); myalgia, 2/12 (17%); alopecia, 1/12 (8%); tenosynovitis, 1/12 (8%) and monoarthritis, 1/12 (8%).In addition, two patients reported worsening Raynaud's phenomenon [2/12 (17%)] and one worsening livedo reticularis [1/12 (8%)].In two patients with known osteoarthritis, the features of the flare could not obviously be accounted for by this nor by an exacerbation of fibromyalgia.No clear pattern of changes were observed for the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), immunglobulin (Ig) G, IgA and IgM levels, or complement C3 or C4 levels in accord with previous studies [5].Data on anti-Ro and anti-La antibody titres were available in five patients and, similarly, no clear pattern was seen.Eight flares settled following intramuscular depomedrone injections.In six patients, hydroxychloroquine therapy was initiated and one patient was started on oral prednisolone.Nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed for two patients.All flares settled within 9 months.The overall frequency of flares in our cohort at 3-7% per year is much less than that in SLE (62% per year [2]) and the frequency of flares involving the general or musculoskeletal systems also appears substantially lower than in SLE [2].We did not attempt to assess the severity of the flares in relation to the need for therapy but subjectively they appeared modest in severity and settled over weeks to months with modest therapy.In particular, we did not see any exacerbations involving internal organ systems such as pulmonary or haematological features, although these have been well described in other cohorts [6].Although the numbers were too small for statistical analysis, two out of three flares that were not treated lasted for over 6 months (Table 1), compared with one out of nine for which treatment was given.This descriptive study is limited by its retrospective nature and lack of data from comparison groups.It does, however, provide preliminary data to guide the design of standardized activity and damage measures for PSS based on the BILAG and SLICC measures used in SLE [7,8].These should enable us to characterize the systemic features of PSS and their variation over time in more detail in a prospective study.
Objective. Using a rabbit model, we investigated the DNA oxidation injury occurring in bone following steroid administration and focused on the relation between DNA oxidation injury and osteonecrosis.Methods. Japanese white rabbits weighing about 3.5 kg were injected with a single intramuscular dose of methylprednisolone 4 mg/kg and divided into groups consisting of 10 rabbits each, which were killed after 3, 5 and 14 days (groups A, B and C respectively). As a control, five untreated rabbits (group N) were also studied. An immunohistochemical study of the diaphysis of the proximal femur was conducted using the monoclonal antibody N45.1, which is a highly specific antibody against 8-hydroxy-2'-deoxyguanosine, an index of DNA oxidation injury. Also, using NIH Image freeware, the positive area (8-OHdG %PA) of each group was calculated and the four groups were compared.Results. Osteonecrosis was detected only in group C (70%). N45.1 positivity was noted in bone marrow haematopoietic cells and was particularly marked in groups B and C. 8-OHdG %PA was 1.6 +/- 0.2% in group N, 2.2 +/- 0.4% in group A, 4.8 +/- 0.4% in group B and 5.1 +/- 0.5% in group C, with significantly greater oxidation injury found in groups B and C (P < 0.001).Conclusion. Oxidative injury was demonstrated soon after the administration of methylprednisolone in a rabbit model prior to the development of osteonecrosis. This finding may suggest new strategies to prevent steroid-induced osteonecrosis, such as the optimally timed (early) administration of antioxidant agents.
namely mild facial swelling and arthralgia.No further therapy was administered.Her B cells had depleted (CD19 ¼ 1.4%).Three months later, our patient continues to improve; her haemoglobin is 11.8 g/dl and platelet count 275 Â 10 9 /l.This is mirrored by an improvement in some of her SLE markers, namely double-stranded DNA of 300 IU/ml and C3 of 0.44 g/l.However, on this occasion her albumin and urine protein/creatinine ratio has not changed.We surmise that her renal disease has now progressed to the stage of damage rather than just activity.This case report not only demonstrates that B-cell depletion is effective in the management of patients with severe resistant SLE, but that in the presence of host antibody against the chimeric anti-CD20 monoclonal antibody rituximab, the humanized anti-CD20 antibody hA20 appeared to be effective.This response may be due to the fact that the antibody hA20 has fewer murine amino acid sequences in the variable region.The variable clinical response to the different anti-CD20 antibodies may thus be analogous to the different responses to TNF-alpha blocking agents used in patients with rheumatoid arthritis.However, it is also plausible the response is due to an unknown mechanism that is independent of the chimeric variable region.
Key messagesEtanercept, while being very effective in controlling severe joint disease, may cause optic neuritis in some patients with oligoarticular juvenile idiopathic arthritis.Ophthalmological monitoring is important.
OBJECTIVESOne of the unresolved challenges posed in giant cell (temporal) arteritis (GCA) is the detection and monitoring of large-artery complications, particularly aortitis. Recent investigations support vascular magnetic resonance imaging (MRI) studies in this issue. We report our preliminary experience with this imaging technique in the study of the aorta and its proximal branches in patients with GCA and/or polymyalgia rheumatica (PMR).METHODSBetween 2000 and 2003, six patients with GCA and/or PMR seen in our department were diagnosed with aortitis using vascular MRI studies. In all cases, the study was performed according to a specifically designed protocol that included MRI and MR angiography (MRA).RESULTSMRI was a hepful non-invasive method for diagnosis of aortitis in all cases, providing accurate information about its extent. In particular, MRI had a higher ability to detect earlier stages of vasculitis disclosing subclinical aortitis in five of the six patients. The main signs of early vascular inflammation observed were vessel wall thickness and oedema (six cases) and increased mural enhancement on postcontrast T1-weighted images (four cases). MRA disclosed lumen changes (stenosis) in two patients. On follow-up studies, whereas vascular stenosis and vessel wall thickness remained invariable, vascular wall oedema and contrast enhancement improved significantly when disease activity decreased.CONCLUSIONMRI may be a useful technique for diagnosing patients with occult major artery involvement in GCA, whether presenting with classic symptoms of temporal arteritis or PMR. Its utility for monitoring the course of the disease and response to treatment requires further confirmation.
Poster Session 3. Scleroderma and related disordershancement affecting the distal radius as well as the proximal carpal row and proximal aspect of the hamate.The joint fluid subsequently yielded a pure growth of Pseudomonas aeruginosa.The patient was commenced on oral ciprofloxacin in accordance with sensitivity studies.He underwent 3 washouts of the left wrist within the first week of diagnosis due to the complex nature of his septic arthritis and slow response to conservative treatment.Conclusions: P. aeruginosa is a gram negative aerobe which is widely distributed with a predilection for moist environments.Bone and joint infections are well recognised but unusual and to the best of our knowledge no cases of p. aeruginosa wrist joint sepsis have been reported.The other point of interest is the atypical presentation of septic arthritis in this case.
Objective. To assess the effectiveness of intra-articular triamcinolone injection and physiotherapy singly or combined in the treatment of adhesive capsulitis of the shoulder. Methods. Eighty patients with adhesive capsulitis of less than 6 months duration were randomized to one of four groups: Group A, injection of triamcinolone 20 mg and eight sessions of standardized physiotherapy; Group B, injection of triamcinolone 20 mg alone; Group C, placebo injection and eight sessions of standardized physiotherapy; or Group D, placebo injection alone. All subjects were given an identical home exercise programme. Outcome measures were assessed at 6 weeks and 16 weeks. The primary outcome measure was Shoulder Disability Questionnaire (SDQ) score. Secondary outcomes were measurement of pain using a visual analogue scale (VAS), global disability using VAS and range of passive external rotation. A two-way analysis of variance was used to explore the effects of corticosteroid injection and physiotherapy. Results. At 6 weeks, the SDQ had improved significantly more in the groups receiving corticosteroid injection (P = 0.004). Physiotherapy improved passive external rotation at 6 weeks (P = 0.02) and corticosteroid injection improved self-assessment of global disability at 6 weeks (P = 0.04). There was no interaction effect between injection and physiotherapy. At 16 weeks, all groups had improved to a similar degree with respect to all outcome measures. Conclusion. Corticosteroid injection is effective in improving shoulder-related disability, and physiotherapy is effective in improving the range of movement in external rotation 6 weeks after treatment.
OBJECTIVES To analyse the effect of a dose increase in patients with severe rheumatoid arthritis (RA) with insufficient clinical response to 3 mg/kg infliximab every 8 weeks. METHODS Patients suffering from active refractory RA despite methotrexate, were treated with i.v. infusions of infliximab (3 mg/kg) on week 0, 2, 6 and every 8 weeks thereafter. Based on the clinical judgement at week 22, patients received a dose increase of 100 mg from week 30 on. The American College of Rheumatology (ACR) core set for disease activity measures was regularly assessed. RESULTS Five hundred and eleven RA patients were included. At week 22, 61.4, 34 and 14.1% of all patients met ACR 20, ACR 50 and ACR 70 criteria, respectively, and 6.1% of patients were in remission. A low swollen joint count at baseline was correlated with improvement at week 22 for ACR 20 (P < 0.06), ACR 50 (P < 0.06) and ACR 70 (P < 0.005). The change in HAQ score between weeks 0 and 22 was predictive for response at week 54 (P < 0.01). The dose of infliximab was increased by 100 mg in 22% of the patients. Most baseline values of patients requiring dose increase were higher (P < or = 0.001) than the baseline values of the remaining patients. Increasing the dose of infliximab by one vial from week 30 on could circumvent the partial loss of response in these patients. CONCLUSION Infliximab use in this large out-patient cohort resulted in a significant clinical improvement. A subgroup that partially lost response during the first 22 weeks could regain response by adding 100 mg of infliximab to the subsequent doses. Due to the current study design, however, a regression to the mean like effect could not be ruled out.
Objectives. Autoimmune diseases have been associated with some organ non-specific rheumatological disorders such as rheumatoid arthritis and systemic lupus erythematosus; however, few studies have been performed in an extensive cohort of children with juvenile idiopathic arthritis (JIA). Our objective was to evaluate the thyroid function and the prevalence of antithyroid antibodies, autoimmune thyroiditis and coeliac disease in children with JIA.Methods. One hundred and fifty-one children (120 female, 31 male, median age 8.3 yr, range 2.4-16.9 yr) with JIA were evaluated. All patients underwent thyroid function tests (u-TSH, free T-4 and free T-3), antithyroglobulin (TgA) and antiperoxidase (TPOA) antibodies, antigliadin, anti-endomysium and antitransglutaminase antibodies. All patients with raised thyroid stimulating hormone levels, low thyroid hormone levels or positive TPOA and/or TgA values had a thyroid high-resolution sonography examination. Coeliac disease was confirmed by jejunal biopsy if the specific antibodies profile was positive. One hundred and fifty-eight age- and sex-matched Caucasian children from the same geographical area acted as controls.Results. Fourteen (9.3%) patients showed subclinical hypothyroidism, 17 (11.9%) patients showed autoimmune thyroiditis with nine patients also showing a non-homogeneous thyroid parenchyma at ultrasound evaluation. Coeliac disease was demonstrated in 10 (6.6%) patients. Compared with controls, JIA patients had higher prevalence of subclinical hypothyroidism (P < 0.01), autoimmune thyroiditis (P < 0.0001) and coeliac disease (P < 0.005).Conclusions. JIA children have an increased prevalence of autoimmune thyroiditis, subclinical hypothyroidism and coeliac disease. These data seem to suggest careful monitoring of thyroid function, thyroid autoantibodies and coeliac disease in JIA children.
Background: Synovitis of rheumatoid arthritis (RA) is characterized by infiltration of innate and adaptive immune cells into the synovial tissue of affected joints.A Th1/Th2 cytokine imbalance with a predominance of Th1 cytokines, including IFNg, is suggested to be a hallmark of RA.Here we examined the spontaneous basal IFNg and IL-10 production of synovial tissue cells (STC) of patients with active RA and the modulatory capacity of separated autologous peripheral blood T-lymphocytes (PB T-cells).Methods: Synovial tissues of 12 patients with RA according to the criteria of the ACR, which presented with a high local inflammatory activity despite appropriate DMARD treatment requiring surgical synovectomy (disease activity score DAS of 2.3 -5.5) were obtained during the surgical procedure, immediately minced and digested with collagenase.STC were used after an overnight culture for ELISPOT assays to determine the frequency of IFNγ or IL-10 producing cells.In order to obtain untouched autologous CD4 and CD8 positive T-cells these were isolated from peripheral blood by the immune rosetting-technique.ELISPOT assays were done with 1x 10 4 STC alone or in co-culture with either 1x10 4 CD4+ or 1x10 4 CD8+ autologous PB T-cells.Cocultures were either left unstimulated or costimulated with a combination of anti-CD3 and anti-CD28 mAb for 24h.Results: Already unstimulated cells isolated from RA synovial tissue exhibited a frequency of 81.3 (mean spot number, ± 48) IFNγ secreting cells after 24h (n=23), while peripheral PBMNC showed no basal IFNγ secretion.No correlation between number of IFNγ producing cells and disease activity was observed.The cocultures of STC with autologous PB T-cells (n=18) resulted in a significant (p<0,01) decrease of the IFNγ frequency (STC + CD4 pos.PB T-cells: 55.7±22.5;STC + CD8 pos.PB T-cells: 63.5±26.2).This results were confirmed in the co-stimulated setting by using anti CD3/CD28 mAb.In contrast in IL-10 ELISPOT there is an increase of IL-10 producing cells in coculture of STC and PB T-cells (n=4) in comparison to STC alone (n=6) (mean number of spots: STC: 27.2; STC + CD4 pos.PB T-cells: 37.8; STC + CD8 pos PB T-cells: 64.7) Conclusions: IFNγ as well as IL-10 secreting cells are demonstrable in RA synovial materials even in unstimulated conditions.Despite abundant synovial T cell infiltrates in some RA patients, both the CD4+ and CD8+ peripheral blood T cells of RA patients provide regulatory effects on the IFNg and IL-10 production of synovial tissue cells.The therapeutic potential of these PB T-cell subsets warrants further investigation. 25.
Background: Patients with IJD receive a full package of care at diagnosis, appropriate follow-up and planned annual review.The latter includes assessment of disease activity, general health and fitness, social and emotional status as well as self efficacy/knowledge.Many patients suffer loss of confidence in their physical fitness, deterioration in muscle strength and endurance as well as loss of joint range and overall CVS fitness as a result of the disease process.Others achieve prolonged stability and are candidates for advanced exercise programmes.Methods: 23 stable IJD patients (14 with RA, 4 with AS, 5 other) undertook a programme of advanced physical activity, tailored to their own level of fitness.The programme included three sessions in the physiotherapy gym establishing suitability, technique and self-confidence.Thereafter, the Physiotherapy Technical Instructor (PTI -HN) escorted groups of up to six patients to a local fitness facility.The PTI liaised with, instructed and educated the gym staff, individualised the patient programmes and highlighted special considerations.After three sessions with the PTI in attendance subsequent supervision was undertaken by the gym staff.Results were collated via semi-structured patient interviews with written records, focusing on a subjective overview of the benefits and drawbacks.Results: Five major topics were discussed.Physical 18 (78%) objectively improved in ROM; 17 (74%) improved in strength; 23 (100%)were able to significantly increase time and resistance on CVS equipment Functional 21 (91%) patients stated they were able to resume household/DIY tasks 10 (43%) patients reported improvement in personal ADLs Occupational 13 of 17 patients not in employment felt able to consider a return to employment. Confidence/knowledgeAll 23 patients appreciated the benefits of exercise, the relevance of joint symptoms during exercise, skills in joint protection in the gym environment and post exercise symptom management.This produced a new confidence in physical ability.Motivation improved because of increased self-confidence, self-esteem and body image.Medical intervention 14 (61%) of patients were able to reduce their analgesia/NSAIDS.Foot surgery and joint injection was postponed for one patient.Conclusions: Patients achieving stability after conventional physiotherapy can improve still further through controlled engagement in a Health & Fitness facility.The benefits are profound and wide-ranging.The outcome is marked improvement in quality of life.Inclusion in the audit was independent of medication prescribed.However, the 7 patients on anti-TNF therapy had the most dramatic improvements.20 (88%) of the patients have continued to attend the gym with continuing improvement within this "health" setting.
OBJECTIVESTo present the outcome of patients with idiopathic inflammatory myositis, focusing on functional ability and quality of life.METHODSAnalysis was performed using data from 105 adult patients with definitive polymyositis, dermatomyositis or overlap myositis, who were followed up at a single centre. The diagnosis was made between 1979 and 2000 based on Bohan and Peter's criteria. Functional ability was assessed after a minimum follow-up of 3 yr with the Health Assessment Questionnaire Disability Index (HAQDI) and quality of life was measured with the Short Form 36-item questionnaire (SF-36).RESULTSFifteen patients in our cohort died and 87 participated in the evaluation of functional outcome. Functional ability after a median follow-up of 107.1 months (range 36.4-273.3) was heterogeneous. The median HAQDI score was 0.875 (range 0-2.875). Polyphasic or chronic-progressive disease course, osteoporosis and long-term follow-up were predictive of higher HAQDI scores. In terms of quality of life, significant differences from population norms were shown in all domains of the SF-36. There were no significant differences in the SF-36 scores among the patients according to clinicopathological subset or disease course.CONCLUSIONSAlthough the mortality of our cohort was favourable, myositis continues to have a great impact on life in the medium and long term. The present work indicates that myositis patients have a significantly poorer quality of life than the normal population, but there was no difference among the patients according to clinicopathological subsets.
OBJECTIVES:Hormonal factors playing a role in bone mass and body composition have been rarely assessed in rheumatoid arthritis (RA). In this study, we aimed to evaluate the growth hormone (GH)-insulin-like growth factor-I (IGF-I)-insulin-like growth factor binding protein-3 (IGFPB-3) axis and serum leptin levels in patients with RA and to determine whether these hormonal/growth factors may influence bone mass and body composition in RA.METHODS:Serum GH, IGF-I, IGFPB-3 and leptin were evaluated in 38 corticosteroid-treated RA patients, 14 non-RA patients under corticosteroids (corticosteroid controls, CC) and 32 healthy controls (HC). Bone density was evaluated using dual X-ray absorptiometry (DEXA), and expressed as bone mineral density (BMD), and quantitative ultrasound (QUS). Body composition was assessed by DEXA.RESULTS:The three groups differed regarding femoral neck, total body BMD, lean mass and QUS parameters with lower values in the RA group (all P < or = 0.05). Growth hormone was higher in RA patients (P=0.0001) while IGF-I and IGFBP-3 did not differ between the three groups. In RA patients there was a tendency to high serum leptin levels and leptin strongly correlated with fat mass (r=0.83, P<0.0001), but not with bone mass measurements or inflammatory parameters. There were no differences for lean mass, GH and leptin between CC and HC.CONCLUSION:Our results suggest that these GH and leptin modifications could have an influence on both bone mass and body composition in RA.
Concurrent Orals -BSR/BATS Joint Sessionpolymorphisms in a range of different populations.Associations have also been reported for CTLA4 in other autoimmune diseases, raising the possibility that CTLA4 polymorphism has significant functional sequelae that may predispose to autoimmunity.Methods: We undertook a detailed examination of polymorphisms across CTLA4 to look for associations to SLE.The laboratory has a collection of genomic DNA from 881 SLE families, mainly single case nuclear families of European Caucasian origin.All probands conformed to the ACR criteria for SLE.The study cohort consists of 474 European Caucasian families.The 20 genotyped variants were selected from a series of haplotype-tagging SNPs provided by John Todd.Additional polymorphisms were chosen from the SNP databases and the literature.The polymorphisms were typed by MALDI-TOF mass spectrometry.An initial haplotype map in our SLE trios was constructed in Haploview.TDT analysis using GENEHUNTER was performed on trios and using TRANSMIT to include single parent families.Replication was sought in an independent US European Caucasian population of SLE families.Results: A single SNP was associated to SLE in the promoter of CD28 (p = 0.003), and 4 SNPs in the 3' flanking region of CTLA4: SNP 12 (p = 7x10 -4 ), SNP 13 (p = 0.019), SNP 14 (p = 0.006) and SNP 16 (p = 0.019).This association is in the same region of CTLA4 associated with other autoimmune diseases including T1D and Graves' disease.The association for SNPs 13 and 14 was replicated in the US population (p = 0.04 and 0.03 respectively).Conclusions: Association to SLE in this region is focused in the CTLA4 3' flanking region and in the CD28 promoter.We are currently fine-mapping the associated haplotypes in both genes.Polymorphisms in the 3' flanking region of CTLA4 have been shown to be correlated to lower levels of the soluble alternatively spliced form of CTLA4 mRNA in normal PBMCs.We will seek to quantify allelic-specific differences in levels of full-length and alternatively spliced mRNAs between SLE cases and healthy controls.
