Predictors of outcome and immunological markers in patients with Systemic lupus erythematosus

Background Systemic lupus erythematosus (SLE) is the prototypic multisystem autoimmune disease, with a broad spectrum of clinical presentations encompassing almost all organs and a chronic course, which can vary from mild to life-threatening. There is a major unmet need for outcome prediction enabling tailoring management and therapeutic interventions for SLE patients. Objectives To improve outcome prediction in SLE, the specific aims of this thesis were: (1) to evaluate the performance of the ACR and the SLICC classification criteria sets for SLE; (2) to evaluate the effect of the classification criteria fulfilled at time of SLE diagnosis and other predictors on long-term outcomes of damage and mortality; (3) to identify clinical predictors for SLE flares of disease activity; (4) to increase knowledge about the relationships between immunological markers and SLE disease activity. Methods We conducted a cross-sectional observational study of 2055 patients with a clinical diagnosis of SLE followed at 17 centers and registered in the Portuguese and Spanish national registries; the sensitivity of the ACR and SLICC classification criteria was compared using the McNemar’s test; the sensitivity of the two classification sets was further examined in five subgroups defined according to disease duration. We conducted a prospective inception cohort study of 192 SLE patients from time of diagnosis and followed up to 10 years at the CHUC Lupus Clinic; we assessed with multivariate Cox models the 10-year outcomes of damage and mortality, according to SLE classification status (fulfilling the ACR or only the SLICC criteria) at inception, and adjusting for potential baseline confounders. We conducted a prospective cohort study of 202 SLE patients followed up to 24 months at the CHUC Lupus Clinic over 1083 visits; we evaluated potential clinical predictors for disease activity flares with multivariate Cox regression models adjusting for potential confounders factors and estimating hazard ratios. We conducted cross-sectional studies of two groups of SLE patients, one with clinically active and another with inactive disease recruited at the CHUC Lupus Clinic and a group of healthy subjects enrolled at the same site; one peripheral blood sample was collected from each participant and analyzed with flow cytometry multiparametric immunophenotyping protocols to define relationships between immunological markers in B cells, Th17 cells and NK cells and SLE classification and disease activity status. Results The cross-sectional study on performance of classification criteria showed that the sensitivity for SLE clinical diagnosis was higher with the SLICC than with the ACR classification criteria (93.2% versus 85.6%, p<0.0001). From patients not fulfilling the ACR criteria, 62.8% could be classified with the SLICC. Patients within 5 years since disease onset presented the largest difference in sensitivity between the SLICC and the ACR criteria (respectively 89.3% and 76.0%, p<0.0001). In the 10-year prospective inception cohort study, patients meeting the ACR criteria compared to those with only the SLICC criteria at inception presented during follow-up with more cases of lupus nephritis (35.1% versus 13.8%, p<0.01), but less thrombotic antiphospholipid syndrome (4.5% versus 17.2%, p<0.01). The Cox models showed no significant differences in risk for damage or death between groups. In the 24-month prospective cohort study, the multivariate Cox models demonstrated that the risk of flare was more than two-fold, four-fold and three-fold higher for patients with SLE diagnosis up to 25 years, previous lupus nephritis or baseline immunosuppressant treatment, respectively. In the cross-sectional immunophenotyping studies, analysis of B cell subsets showed that differential expression of BAFFR, CD81 and CD38 in the transitional B cells allowed identifying two major clusters: the cluster 1 integrated all healthy subjects and 79% of SLE patients with clinically inactive disease, while in the cluster 2 there was only patients with SLE and 82% of those with clinically active disease. The analysis of Th17 cells showed no significant differences in the frequency of Th17 among healthy subjects and SLE patients, as well as among patients with clinically inactive and active disease. The analysis of NK cells showed a lower number and frequency of NK cells in SLE patients as compared to healthy subjects, regardless of disease activity status, and a lower frequency of CD56dim NK cells expressing CXCR3 was a marker of clinically active SLE (12.5% versus 24.1% in the active and inactive SLE group, respectively, p<0.01). Conclusions The SLICC classification criteria are more sensitive and may allow a SLE classification earlier in the disease course than the previous ACR criteria. Patients fulfilling at inception either of the classification criteria present no differences in the major long-term outcomes of organ damage and mortality. Patients with a SLE diagnosis before age 25, lupus nephritis or immunosuppressant treatment/severe SLE present higher risk for flares of disease activity; patients fulfilling at inception only the SLICC classification criteria may present higher risk of thrombotic antiphospholipid syndrome: these clinical predictors thus provide a basis for tailoring management strategies of SLE patients. Immunophenotyping studies suggested that SLE patients present: an upregulation of B cells, with subset clusters able to differentiate SLE patients from healthy subjects and clinically active from inactive SLE; a downregulation of NK cells, and less clear changes of Th17 cells. We provide proof-of-concept that a panel of immunological markers may provide a basis for biologic validation of clinical definitions for SLE disease activity states.Introdução O Lúpus Eritematoso sistémico (LES) representa o paradigma das doenças autoimunes multissistémicas, apresentando um largo espectro de manifestações clínicas que potencialmente envolvem quase todos os órgãos e sistemas, com um curso clínico crónico e gravidade clínica variada, entre ligeira a severa e com risco de vida. Existe uma necessidade fundamental por cumprir de identificar preditores de prognóstico que permitam a individualização da monitorização e intervenções terapêuticas para os doentes com LES. Objetivos Identificar preditores de prognóstico em doentes com LES, através dos objetivos específicos desta tese: (1) avaliar o desempenho dos critérios de classificação ACR e SLICC para a identificação de doentes com LES; (2) avaliar o efeito dos critérios de classificação preenchidos à data de diagnóstico de LES e outros preditores no prognóstico a longo prazo em termos de dano irreversível e mortalidade; (3) identificar preditores clínicos para agudizações da atividade clínica do LES; (4) contribuir para o conhecimento das relações entre marcadores imunológicos e a atividade clínica do LES. Métodos Efetuámos um estudo observacional transversal de 2055 doentes com diagnóstico clínico de LES, seguidos em 17 centros e integrados nos registos nacionais de Portugal e Espanha; a sensibilidade dos critérios de classificação ACR e SLICC foi comparada através do teste de McNemar; a sensibilidade dos dois sistemas de classificação foi ainda analisada em 5 subgrupos definidos de acordo com a duração da doença. Realizámos um estudo prospetivo de coorte, incluindo 192 doentes com LES avaliados desde a data de diagnóstico e seguidos até 10 anos na CHUC Lupus Clinic; analisámos através de regressão multivariada de Cox o prognóstico a 10 anos, em termos de dano irreversível e mortalidade, em grupos definidos de acordo com os critérios de classificação cumpridos à data de diagnóstico (critérios ACR ou apenas os critérios SLICC) e ajustando para potenciais confundidores definidos à data de diagnóstico. Conduzimos um estudo prospetivo de coorte incluindo 202 doentes com LES seguidos até 24 meses na CHUC Lupus Clinic ao longo de 1083 consultas; analisámos potenciais preditores clínicos de agudizações da atividade do LES, aplicando regressão multivariada de Cox ajustada a potenciais confundidores e com estimativa dos hazard ratios dos preditores. Efetuámos estudos transversais incluindo dois grupos de doentes com LES, um com doença clinicamente ativa e outro com doença inativa, recrutados na CHUC Lupus Clinic e um grupo de indivíduos saudáveis recrutados no mesmo local; colhemos uma amostra de sangue periférico de cada participante, que foi processada através de protocolos de imunofenotipagem e analisada com citometria de fluxo multiparamétrica, para identificar relações entre marcadores imunológicos em células B, Th17 e NK e a classificação de LES e seus estados de atividade clínica. Resultados O estudo transversal do desempenho dos critérios de classificação demonstrou que a sensibilidade para o diagnóstico clínico de LES é mais elevado com o sistema de classificação SLICC do que com o ACR (93,2% e 85,6%, respetivamente, p<0,0001). Entre os doentes que não cumpriam os critérios ACR, 62,8% preencheram os critérios SLICC. Os pacientes com duração de doença até 5 anos apresentaram a maior diferença em sensibilidade entre o sistema SLICC e ACR de classificação (respetivamente 89,3% e 76,0%, p<0001). O estudo prospetivo de coorte de LES inicial e seguimento até 10 anos, mostrou que os doentes que preenchiam à data de diagnóstico os critérios ACR de classificação apresentaram ao longo do seguimento mais casos de nefrite lúpica do que aqueles cumprindo apenas critérios SLICC (35,1% e 13,8%, respetivamente, p<0,01), mas menos casos de síndrome antifosfolípido trombótico (4,5% e 17,2%, respetivamente, p<0,01). Os modelos multivariados de Cox não mostraram diferenças entre grupos no risco de dano irreversível nem de mortalidade. No estudo prospetivo de coorte com seguimento a 24 meses, os modelos multivariados de Cox demonstraram que o risco de agudizações clínicas do LES é mais de 2 vezes, 4 vezes e três vezes mais elevado para os doentes com diagnóstico de LES até aos 25 anos, com nefrite lúpica prévia ou sob terapêutica com imunossupressores à data de inclusão, respetivamente. Nos estudos transversais de imunofenotipagem, a análise da linhagem de células B demonstrou que a expressão diferencial de BAFFR, CD81 e CD38 nas células B de transição permite a identificação de dois principais clusters: o cluster 1, que integrou todos os indivíduos saudáveis e 79% dos doentes com LES clinicamente inativo, enquanto o cluster 2 incluiu apenas doentes com LES e 82% daqueles com doença clinicamente ativa. A análise das células Th17 mão mostrou diferenças significativas na frequência de Th17 entre o grupo de controlos e o de doentes com LES, nem entre pacientes com doença clinicamente inativa ou ativa. A análise das células NK revelou menor número e frequência de células NK em doentes com LES comparativamente aos controlos, independentemente da atividade clínica da doença; uma frequência mais baixa de células NK CD56dim expressando CXCR3 revelou ser um marcador de LES clinicamente ativo (12,5% e 24,1% no grupo com doença ativa e inativa, respetivamente, p<0,01). Conclusões Os critérios de classificação SLICC apresentam maior sensibilidade e podem permitir estabelecer a classificação como LES mais precocemente no curso da doença do que o prévio sistema de classificação ACR. Os doentes preenchendo à data de diagnóstico qualquer dos dois sistemas de classificação não apresentam diferenças no prognóstico a longo prazo em termos de dano irreversível nem de mortalidade. Os doentes com diagnóstico de LES até aos 25 anos, com nefrite lúpica ou necessitando terapêutica imunossupressora, apresentam risco mais elevado de sofrer agudizações clínicas do LES; pacientes preenchendo à data de diagnóstico apenas os critérios de classificação SLICC podem apresentar maior risco de síndrome anti-fosfolípido trombótico: estes preditores clínicos fornecem uma base para individualizar estratégias de monitorização e tratamento de doentes com LES. Os estudos de imunofenotipagem sugerem que os doentes com LES apresentam: hiperatividade de células B, com clusters de marcadores imunológicos em subtipos de células B que permitem diferenciar doentes com LES de indivíduos saudáveis e LES clinicamente ativo de inativo; hipoatividade das células NK e anomalias menos consistentes das células Th17. Fizemos prova do conceito que um painel de marcadores imunológicos pode providenciar uma base de validação biológica para definições clínicas de estados de atividade do LES

Modelling environmental monitoring data coming from different surveys

With this work we propose a spatio-temporal model for Gaussian data collected in a small number of surveys. We assume the spatial correlation structure to be the same in all surveys. In the application concerning heavy metal concentrations in mosses, the data set is dense in the spatial dimension but sparse in the temporal one, thus our model-based approach corresponds to a correlation model depending on survey orders. One advantage of this approach is its computational simplicity. An interpretation for the space-time covariance function, decomposing the overall variance of the process as the product of the spatial component variance by the temporal component variance, is introduced. A simulation study, aiming to validate the model, provided better results in terms of accuracy with the novel covariance function. Maps of predicted heavy metal concentrations and of interpolation error, for the most recent survey, are presented.Data of this kind is recurrent in environmental sciences, which is why we argue that this will be a practical tool to be used very often

Marginal microleakage of flowable resin composites used to adhere Semi-Direct restorations

Abstract in proceedings of the Fourth International Congress of CiiEM: Health, Well-Being and Ageing in the 21st Century, held at Egas Moniz’ University Campus in Monte de Caparica, Almada, from 3–5 June 2019.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.info:eu-repo/semantics/publishedVersio

Volatiles from Coriandrum sativum: comparation of in vitro and ex vitro grown plants

Coriandrum sativum (coriander) is commonly used, raw or cooked, in Portuguese Gastronomy. Coriander is also used in traditional medicine as a carminative and as a digestive aid. The fruits essential oil is used in food flavouring and in perfumery and is also responsible for the digestive and stimulant effect as well as for fungicide and bactericidal activity

In-Situ Tests on Silica Aerogel-Based Rendering Walls

In this paper, two aerogel-based renders are characterized based on in-situ testing of walls prototypes. The in-situ tests to assess the mechanical performance are: pull-off, surface impact tests and compressive strength on collected samples. The physical performance includes the water resistance and thermal conductivity coefficient. The tests carried out to assess water-resistance are: Karsten tube, moisture meter and capillary water absorption of collected samples. The thermal performance was tested based on infrared thermography and thermal conductivity transient method. The combination of these in-situ tests allowed a better performance characterization of the aerogelbased renders and characterized the applied renders. These results were carried out under two national research projects (Nanorender and P2020 PEP)

A Search for Novel Legionella pneumophila Effector Proteins Reveals a Strain Specific Nucleotropic Effector

Legionella pneumophila is an accidental human pathogen that causes the potentially fatal Legionnaires' disease, a severe type of pneumonia. The main virulence mechanism of L. pneumophila is a Type 4B Secretion System (T4SS) named Icm/Dot that transports effector proteins into the host cell cytosol. The concerted action of effectors on several host cell processes leads to the formation of an intracellular Legionella-containing vacuole that is replication competent and avoids phagolysosomal degradation. To date over 300 Icm/Dot substrates have been identified. In this study, we searched the genome of a L. pneumophila strain (Pt/VFX2014) responsible for the second largest L. pneumophila outbreak worldwide (in Vila Franca de Xira, Portugal, in 2014) for genes encoding potential novel Icm/Dot substrates. This strain Pt/VFX2014 belongs to serogroup 1 but phylogenetically segregates from all other serogroup 1 strains previously sequenced, displaying a unique mosaic genetic backbone. The ability of the selected putative effectors to be delivered into host cells by the T4SS was confirmed using the TEM-1 β-lactamase reporter assay. Two previously unknown Icm/Dot effectors were identified, VFX05045 and VFX10045, whose homologs Lpp1450 and Lpp3070 in clinical strain L. pneumophila Paris were also confirmed as T4SS substrates. After delivery into the host cell cytosol, homologs VFX05045/Lpp1450 remained diffused in the cell, similarly to Lpp3070. In contrast, VFX10045 localized to the host cell nucleus. To understand how VFX10045 and Lpp3070 (94% of identity at amino acid level) are directed to distinct sites, we carried out a comprehensive site-directed mutagenesis followed by analyses of the subcellular localization of the mutant proteins. This led to the delineation of region in the C-terminal part (residues 380 to 534) of the 583 amino acid-long VFX10045 as necessary and sufficient for nuclear targeting and highlighted the fundamental function of the VFX10045-specific R440 and I441 residues in this process. These studies revealed a strain-specific nucleotropism for new effector VFX10045/Lpp3070, which anticipates distinct functions between these homologs.This project has been funded by: Research Grant 2016 by the European Society of Clinical Microbiology and lnfectious Diseases (ESCMID) to IF; by National funds from FCT - Fundação para a Ciência e a Tecnologia, I.P., in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of the Research Unit on Applied Molecular Biosciences - UCIBIO and the project LA/P/0140/2020 of the Associate Laboratory Institute for Health and Bioeconomy - i4HB.info:eu-repo/semantics/publishedVersio

Perception of Portuguese Nurses

Funding: The present study was funded by the Center for Research, Innovation, and Development in Nursing, in Portugal, by means of grants provided to some of the authors.The COVID-19 pandemic brought many changes and challenges to health professionals, due to a lack of knowledge when dealing with the disease, fear of contagion, and the sequelae that characterize long COVID. To deal with this situation, respiratory rehabilitation programs are recommended in face-to-face and/or telerehabilitation modalities. (1) Background: This study had as its primary aim identifying the aspects/components to be considered in the planning and implementation of telerehabilitation interventions that guarantee transitional care for people with long COVID-19 after hospitalization and as a secondary aim identifying the positive aspects of telerehabilitation. (2) Methods: The method used to answer the research question was a focus group, carried out online with eight nurses specialized in rehabilitation nursing. The answers to the semi-structured interview were subjected to content analysis, and qualitative data analysis software (WebQDA®) was used to organize and analyze the findings. (3) Results: Four categories emerged from the content analysis: coordination between care levels; transitional care telerehabilitation intervention; advantages of telerehabilitation; and opportunities. (4) Conclusions: These findings make an important contribution to the reorganization of transitional care, allowing the identification of central aspects to be considered in the planning and implementation of telerehabilitation programs for people with long COVID.publishersversionpublishe