Search results for: systemic lupus Erythemotosus

Authors: Fathia Ehmouda Zaid, Reim Abudelnbi

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Cardiovascular disease is a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Patients and method: Cross-section study (68) patients diagnosed as systemic lupus erythematosus (SLE), who visited the outpatient clinic of rheumatology, these patients were interviewed with a structured questionnaire about their past and current clinically for presence of Cardiovascular disease in systemic lupus and use SLEDAI, specific tests [ECG –ECHO –CXRAY] the data are analyzed statistically by Pearson's correlation coefficient was calculated and statistical significance was defined as P< 0.05,during period (2013-2014). Objective: Estimation Cardiovascular disease manifestation of systemic lupus erythematosus, correlation with disease activity, morbidity, and mortality. Result: (68) Patients diagnosed as systemic lupus erythematosus' age range from (18-48 years), M=(13±29Y), Sex were female 66/68 (97.1%), male 2/68 (2.9%),duration of disease range[1-15year], M =[7±8y], we found Cardiovascular disease manifestation of systemic lupus erythematosus 32/68 (47.1%), correlation with disease activity use SLEDAI,(r= 476** p=0.000),Morbidity,(r= .554**; p=0.000) and mortality (r=.181; p=.139), Cardiovascular disease manifestations of systemic lupus erythematosus are pericarditis 8/68 (11.8%), pericardial effusion 6/68 (8.8%), myocarditis 4/68 (5.9 %), valvular lesions (endocarditis) 1/68 (1.5%), pulmonary hypertension (PAH) 12/68 (17.6%), coronary artery disease 1/68 (1.5%), none of patients have conduction abnormalities involvement. Correlation with disease activity use SLEDAI, pericarditis (r= .210, p=.086), pericardial effusion (r= 0.079, p=.520), myocarditis (r= 272*, p=.027), valvular lesions (endocarditis) (r= .112, p= .362), pulmonary hypertension (PAH) (r= .257*, p=.035) and coronary artery disease (r=.075, p=.544) correlation between cardiovascular disease manifestations of systemic lupus erythematosus and specific organ involvement we found Mucocutaneous (r=.091 p= .459), musculoskeletal (MSK) (r=.110 p=.373), Renal disease (r=.278*, p=.022), neurologic disease (r=.085, p=.489) and Hematologic disease (r=-.264*, p=.030). Conclusion: Cardiovascular manifestation is more frequent symptoms with systemic lupus erythematosus (SLE) is 47 % correlation with disease activity and morbidity but not with mortality. Recommendations: Focus research to evaluation and an adequate assessment of cardiovascular complications on the morbidity and mortality of the patients with SLE are still required.

Keywords: cardiovascular disease, systemic lupus erythematosus, disease activity, mortality

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Authors: Lorena GóMez Escorcia, Gustavo Aroca MartíNez, Jose Luiz Villarreal, Elkin Navarro Quiroz

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Lupus nephritis (LN) is a high-cost disease, occurring in about half of patients with Systemic Lupus Erythematosus (SLE). Renal biopsy constitutes the only protocol that, to date, allows a correct diagnosis of the level of renal involvement in these patients. However, this procedure can have various adverse effects such as kidney bleeding, muscle bleeding, infection, pain, among others. Therefore, the development of new diagnostic alternatives is required. The neutrophil gelatinase-associated lipocalin (NGAL) has been emerging as a novel biomarker of acute kidney injury. The aim of this study was to assess urinary NGAL levels as a marker for disease activity in patients with lupus nephritis. For this work included 50 systemic lupus erythematosus (SLE) patients, 50 with active lupus nephritis (LN), and 50 without autoimmune and renal disease as controls. TNGAL in urine samples was measured by enzyme-linked immunosorbent assay (ELISA). The results revealed that patients with kidney damage had an elevated urinary NGAL as compared to patients with lupus without kidney damage and controls (p <0.005), and the mean of uNGAL was (28.72 ± 4.53), (19.51 ± 4.72), (8.91 ± 3.37) respectively. Measurement of urinary NGAL levels showed a very good diagnostic performance for discriminating patients with Lupus nephritis from SLE without renal damage and of control individuals.

Keywords: lupus nephritis, biomarker, NGAL, urine samples

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Authors: H. Zidoum, A. AlShareedah, S. Al Sawafi, A. Al-Ansari, B. Al Lawati

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Systemic lupus erythematosus (SLE) is an autoimmune disease with genetic and environmental components. SLE is characterized by a wide variability of clinical manifestations and a course frequently subject to unpredictable flares. Despite recent progress in classification tools, the early diagnosis of SLE is still an unmet need for many patients. This study proposes an interpretable disease classification model that combines the high and efficient predictive performance of CatBoost and the model-agnostic interpretation tools of Shapley Additive exPlanations (SHAP). The CatBoost model was trained on a local cohort of 219 Omani patients with SLE as well as other control diseases. Furthermore, the SHAP library was used to generate individual explanations of the model's decisions as well as rank clinical features by contribution. Overall, we achieved an AUC score of 0.945, F1-score of 0.92 and identified four clinical features (alopecia, renal disorders, cutaneous lupus, and hemolytic anemia) along with the patient's age that was shown to have the greatest contribution on the prediction.

Keywords: feature selection, classification, systemic lupus erythematosus, model interpretation, SHAP, Catboost

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Authors: M. Fayez Al Homsi, Reem Al Homsi

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Renal disease is a major cause of morbidity and mortality. Glomerular diseases make a small portion of the renal disease. Lupus glomerulonephritis (GN) is the commonest among the GN of systemic diseases. More than a hundred and eighty-eight consecutive renal biopsies are performed and evaluated for clinically suspected glomerular diseases over a period of two years. As in a standard practice after receiving the ultrasound-guided renal biopsies, the fresh biopsy is divided to three parts, one part is frozen for immunofluorescence evaluation, the second part is placed in 4% glutaraldehyde for electron microscopic evaluation, and the third part is placed in 10% buffered formalin for light microscopic evaluation. Primary glomerular diseases are detected in 83 biopsies; glomerulonephritis (GN) of systemic diseases are identified in 88, glomerular lesions in vascular diseases in 3, glomerular lesions in metabolic diseases in 7, hereditary nephropathies in 2, end-stage kidney in 2, and glomerular lesions in transplantation in 3 biopsies. Among the primary lesions, focal segmental glomerulosclerosis (28) and mesangial proliferative GN (26) were the most common. Lupus GN (67) and Ig A nephropathy (20) were the most common of the GN of systemic diseases. Lupus nephritis biopsies included one biopsy diagnosed as class 1 (normal), 17 biopsies class 2 (mesangial proliferation), 5 biopsies class 3 (focal proliferative GN), 39 biopsies class 4 diffuse proliferative GN), 3 biopsies class 5 (membranous GN), and 2 biopsies class 6 (crescentic GN). Lupus GN is the most common among GN of systemic diseases. While diabetes is very common here, diabetic GN (3 biopsies) is not as common as might one expects. Most likely this is due to sampling and reluctance on part of nephrologists and patients in sampling the kidney in diabetes mellitus.

Keywords: diabetes, glomerulonephritis, lupus, mesangial proliferation, nephropathy

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Authors: Stoyanka Vladeva, Elena Kirilova, Nikola Kirilov

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Background: The creatinine clearance is a widely used value to estimate the GFR. Increased creatinine clearance is often called hyperfiltration and is usually seen during pregnancy, patients with diabetes mellitus preceding the diabetic nephropathy. It may also occur with large dietary protein intake or with plasma volume expansion. Renal injury in lupus nephritis is known to affect the glomerular, tubulointerstitial, and vascular compartment. However high creatinine clearance has not been found in patients with SLE, Target: Follow-up of creatinine clearance values in patients with systemic lupus erythematosus without history of kidney injury. Material and methods: We observed the creatinine, creatinine clearance, GFR and dipstick protein values of 7 women (with a mean age of 42.71 years) with systemic lupus erythematosus. Patients with active lupus have been monthly tested in the period of 13 months. Creatinine clearance has been estimated by Cockcroft-Gault Equation formula in ml/sec. GFR has been estimated by MDRD formula (The Modification of Diet in renal Disease) in ml/min/1.73 m2. Proteinuria has been defined as present when dipstick protein > 1+.Results: In all patients without history of kidney injury we found elevated creatinine clearance levels, but GFRremained within the reference range. Two of the patients were in remission while the other five patients had clinically and immunologically active Lupus. Three of the patients had a permanent presence of high creatinine clearance levels and proteinuria. Two of the patients had periodically elevated creatinine clearance without proteinuria. These results show that kidney disturbances may be caused by the vascular changes typical for SLE. Glomerular hyperfiltration can be result of focal segmental glomerulosclerosis caused by a reduction in renal mass. Probably lupus nephropathy is preceded not only by glomerular vascular changes, but also by tubular vascular changes. Using only the GFR is not a sufficient method to detect these primary functional disturbances. Conclusion: For early detection of kidney injury in patients with SLE we determined that the follow up of creatinine clearance values could be helpful.

Keywords: systemic Lupus erythematosus, kidney injury, elevated creatinine clearance level, normal glomerular filtration rate

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Authors: Recep Kesli, Onur Turkyilmaz, Cengiz Demir

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Objective: Autoimmune collagen diseases occur with the immune reactions against the body’s own cell or tissues which cause inflammation and damage the tissues and organs. In this study, it was aimed to compare seropositivity rates and patterns of the anti-nuclear antibodies (ANA) in the diagnosis of four different autoimmune collagen tissue diseases (Rheumatoid Arthritis-RA, Systemic Lupus Erythematous-SLE, Scleroderma-SSc and Sjogren Syndrome-SS) with each other. Methods: One hundred eighty-eight patients applied to different clinics in Afyon Kocatepe University ANS Practice and Research Hospital between 11.07.2014 and 14.07.2015 that thought the different collagen disease such as RA, SLE, SSc and SS have participated in the study retrospectively. All the data obtained from the patients participated in the study were evaluated according to the included criteria. The historical archives belonging to the patients have been screened, assessed in terms of ANA positivity. The obtained data was analysed by using the descriptive statistics; chi-squared, Fischer's exact test. The evaluations were performed by SPSS 20.0 version and p < 0.05 level was considered as significant. Results: Distribution rates of the totally one hundred eighty-eight patients according to the diagnosis were found as follows: 82 (43.6%) were RA, 38 (20.2%) were SLE, 22 (11.7%) were SSc, and 46 (24.5%) were SS. Distribution of ANA positivity rates according to the collagen tissue diseases were found as follows; for RA were 54 (65,9 %), for SLE were 36 (94,7 %), for SSc were 18 (81,8 %), and for SS were 43 (93,5 %). Rheumatoid arthritis should be evaluated and classified as a different class among all the other investigated three autoimmune illnesses. ANA positivity rates were found as differently higher (91.5 %) in the SLE, SSc, and SS, from the RA (65.9 %). Differences at ANA positivity rates for RA and the other three diseases were found as statistically significant (p=0.015). Conclusions: Systemic autoimmune illnesses show broad spectrum. ANA positivity was found as an important predictor marker in the diagnosis of the rheumatologic illnesses. ANA positivity should be evaluated as more valuable and sensitive a predictor diagnostic marker in the laboratory findings of the SLE, SSc, and SS according to RA.

Keywords: antinuclear antibody (ANA), rheumatoid arthritis, scleroderma, Sjogren syndrome, systemic lupus Erythemotosus

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Authors: Manish Subedi, Bijay Bartaula, Ashok R. Pant, Purbesh Adhikari, Sanjib K. Sharma

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Background: The pattern of glomerular disease varies worldwide. In absence of kidney disease/Kidney biopsy registry in Nepal, the exact etiology of different forms of glomerular disease is primarily unknown in our country. Method: We retrospectively analyzed 175 cases of renal biopsies performed from dated September 2014 to August 2016 at B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Results: The commonest indication for renal biopsy was nephrotic syndrome (34.9%), followed by Systemic lupus erythematosus with suspected renal involvement (22.3%). Majority of patients were in the 30-60 year bracket (57.2%), with the mean age of the patients being 35.37 years. The average number of glomeruli per core was 13, with inadequate sampling in 5.1%. IgA nephropathy (17%) was found to be the most common primary glomerular disease, followed by membranous nephropathy (14.6%) and FSGS (14.6%). The commonest secondary glomerular disease was lupus nephritis. Complications associated with renal biopsy were pain at biopsy site in 18% of cases, hematuria in 6% and perinephric hematoma in 4% cases. Conclusion: The commonest primary and secondary glomerular disease was IgA nephropathy and lupus nephritis respectively. The high prevalence of Systemic lupus erythematosus with lupus nephritis among Nepalese in comparison with other developing countries warrants further evaluation. As an initial attempt towards documentation of glomerular diseases in the national context, this study should serve as a stepping stone towards the eventual establishment of a full-fledged national registry of glomerular diseases in Nepal.

Keywords: glomerular, Nepal, renal biopsy, systemic lupus erythematoses

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Authors: Yousef M. Alammari, Mahmoud A. Gaddoury, Reem A. Almohaini, Sara A. Alharbi, Lena S. Alsaleem, Lujain H. Allowaihiq, Maha H. Alrashid, Abdullah H. Alghamdi, Abdullah A. Alaryni

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Objective: The goal of this study was to establish the prevalence of neuropsychiatric symptoms in systemic lupus erythematosus (NPSLE) patients in Saudi Arabia and the variables that are linked to it. Methods: During June 2021, this cross-sectional study was carried out among SLE patients in Saudi Arabia. The Saudi Rheumatism Association exploited social media platforms to provide a self-administered online questionnaire to SLE patients. All data analyses were performed using the Statistical Packages for Social Sciences (SPSS) version 26. Results: Two hundred and five SLE patients participated in the study (females 91.3 % vs. males 8.7 %). In addition, 13.5 % of patients had a family history of SLE, and 26% had SLE for one to three years. Alteration or loss of sensation (53.4%), Fear (52.4%), and headache (48.1%) were the most prevalent signs of neuropsychiatric symptoms in systemic lupus erythematosus (NPSLE) patients. The prevalence of patients with NPSLE was 40%. In a multivariate regression model, fear, altered sensations, cerebrovascular illness, sleep disruption, and diminished interest in routine activities were identified as independent risk variables for NPSLE. Conclusion: Nearly half of SLE patients demonstrated NP manifestations, with significant symptoms including fear, alteration of sensation, cerebrovascular disease, sleep disturbance, and reduced interest in normal activities. To detect the pathophysiology of NPSLE, it is necessary to understand the relationship between neuropsychiatric morbidity and other relevant rheumatic disorders in the SLE population.

Keywords: neuropsychiatric, systemic lupus erythematosus, NPSLE, prevalence, SLE patients

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Authors: Jemely M. Punzalan, Christine B. Bernal, Beatrice B. Canonigo, Maria Rosario F. Cabansag, Dennis S. Flores, Paul Joseph T. Galutira, Remedios D. Chan

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Background: Systemic lupus erythematosus (SLE) is one of the most common autoimmune disorders predominates in women of childbearing age. Simple Measure of Impact of Lupus Erythematosus in Youngsters (SMILEY) is the only health specific quality of life tool for pediatric SLE, which has been translated to different languages except in Filipino. Objective: The primary objective of this study was to develop a Filipino translation of the SMILEY and to examine the validity and reliability of this translation. Methodology: The SMILEY was translated into Filipino by a bilingual individual and back-translated by another bilingual individual blinded from the original English version. The translation was evaluated for content validity by a panel of experts and subjected to pilot testing. The pilot-tested translation was used in the validity and reliability testing proper. The SMILEY, together with the previously validated PEDSQL 4.0 Generic Core Scale was administered to lupus pediatric patients and their parent at two separate occasions: a baseline and a re-test seven to fourteen days apart. Tests for convergent validity, internal consistency, and test-retest reliability were performed. Results: A total of fifty children and their parent were recruited. The mean age was 15.38±2.62 years (range 8-18 years), mean education at high school level. The mean duration of SLE was 28 months (range 1-81 months). Subjects found the questionnaires to be relevant, easy to understand and answer. The validity of the SMILEY was demonstrated in terms of content validity, convergent validity, internal consistency, and test-retest reliability. Age, socioeconomic status and educational attainment did not show a significant effect on the scores. The difference between scores of child and parent report was showed to be significant with SMILEY total (p=0.0214), effect on social life (p=0.0000), and PEDSQL physical function (p=0.0460). Child reports showed higher scores for the following domains compared to their parent. Conclusion: SMILEY is a brief, easy to understand, valid and reliable tool for assessing pediatric SLE specific HRQOL. It will be useful in providing better care, understanding and may offer critical information regarding the effect of SLE in the quality of life of our pediatric lupus patients. It will help physician understands the needs of their patient not only on treatment of the specific disease but as well as the impact of the treatment on their daily lives.

Keywords: systemic lupus erythematosus, pediatrics, quality of life, Simple Measure of Impact of Lupus Erythematosus in Youngsters (SMILEY)

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Authors: Monika Malik, Pooja Arora, Ruchi Sachdeva, Vishnampettai G. Ramachandran, Rahul Pal

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Apoptotic debris is believed to be the antigenic trigger in lupus. Whether such debris and autoantibodies induced in lupus-prone mice which specifically recognize its constituents can mediate differential effects on innate and humoral responses in such mice was assessed. The influence of apoptotic blebs and apoptotic cell-reactive monoclonal antibodies on phenotypic markers expressed on bone marrow-derived dendritic cells (BMDCs) and secreted cytokines were evaluated. Sera from lupus-prone and healthy mice immunized with the antibodies were analyzed for anti-self reactivity. Apoptotic blebs, as well as somatically-mutated IgG and non-mutated IgM apoptotic-cell reactive monoclonal antibodies, induced the preferential maturation of BMDCs derived from lupus-prone mice relative to BMDCs derived from healthy mice; antibody specificity and cell genotype both influenced the secretion of inflammatory cytokines. Immunization of lupus-prone mice with IgM and IgG antibodies led to hypergammaglobulinemia; elicited antibodies were self-reactive, and exhibited enhanced recognition of lupus-associated autoantigens (dsDNA, Ro60, RNP68, and Sm) in comparison with adjuvant-induced sera. While ‘natural’ IgM antibodies are believed to contribute to immune homeostasis, this study reveals that apoptotic cell-reactive IgM antibodies can promote inflammation and drive anti-self responses in lupus. Only in lupus-prone mice did immunization with IgG auto-antibodies enhance the kinetics of humoral anti-self responses, resulting in advanced-onset glomerulosclerosis. This study reveals that preferential innate and humoral recognition of the products of cell death in an autoimmune milieu influences the indices associated with lupus pathology.

Keywords: antigen spreading, apoptotic cell-reactive pathogenic IgG, and IgM autoantibodies, glomerulosclerosis, lupus

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Authors: Himali Gunasekara, Baddika Jayaratne

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Haematological abnormalities are known to cause Ischemic Stroke or Transient Ischemic Attack (TIA). The identification of haematological correlates plays an important role in a management and secondary prevention. The objective of this study was to describe haematological correlates of stroke and their association between stroke profile. The haematological correlates screened were Lupus Anticoagulant, Dysfibroginemia, Paroxysmal nocturnal haemoglobinurea (PNH), Sickle cell disease, Systemic Lupus Erythematosis (SLE) and Myeloploriferative Neoplasms (MPN). A cross sectional descriptive study was conducted in a sample of 152 stroke patients referred to haematology department of National Hospital of Sri Lanka for thrombophilia screening. Different tests were performed to assess each hematological correlate. Diluted Russels Viper Venom Test and Kaolin clotting time were done to assess Lupus anticoagulant. Full blood count (FBC), blood picture, Sickling test and High Performance Liquid Chromatography were the tests used for detection of Sickle cell disease. Paroxysmal nocturnal haemoglobinurea was assessed by FBC, blood picture, Ham test and Flowcytometry. FBC, blood picture, Janus Kinase 2 (V617F) mutation analysis, erythropoietin level and bone marrow examination were done to look for the Myeloproliferative neoplasms. Dysfibrinogenaemia was assessed by TT, fibrinogen antigen test, clot observation and clauss test. Anti nuclear antibody test was done to look for systemic lupus erythematosis. Among study sample, 134 patients had strokes and only 18 had TIA. The recurrence of stroke/TIA was observed in 13.2% of patients. The majority of patients (94.7%) have had radiological evidence of thrombotic event. One fourth of patients had past thrombotic events while 12.5% had family history of thrombosis. Out of haematological correlates screened, Lupus anticoagulant was the commonest haematological correlate (n=16 ) and dysfibrigonaemia(n=11 ) had the next high prevalence. One patient was diagnosed with Essential thrombocythaemia and one with SLE. None of the patients were positive for screening tests done for sickle cell disease and PNH. The Haematological correlates were identified in 19% of our study sample. Among stroke profile only presence of past thrombotic history was statistically significantly associated with haematological disorders (P= 0.04). Therefore, hematological disorders appear to be an important factor in etiological work-up of stroke patients particularly in patients with past thrombotic events.

Keywords: stroke, transient ischemic attack, hematological correlates, hematological disorders

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Authors: A. Lubis, R. Widayanti, Z. Hikmah, A. Endaryanto, A. Harsono, A. Harianto, R. Etika, D. K. Handayani, M. Sampurna

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Neonatal lupus erythematous (NLE) is a rare disease marked by clinical characteristic and specific maternal autoantibody. Many cutaneous, cardiac, liver, and hematological manifestations could happen with affect of one organ or multiple. In this case, both babies were premature, low birth weight (LBW), small for gestational age (SGA) and born through caesarean section from a systemic lupus erythematous (SLE) mother. In the first case, we found a baby girl with dyspnea and grunting. Chest X ray showed respiratory distress syndrome (RDS) great I and echocardiography showed small atrial septal defect (ASD) and ventricular septal defect (VSD). She also developed anemia, thrombocytopenia, elevated C-reactive protein, hypoalbuminemia, increasing coagulation factors, hyperbilirubinemia, and positive blood culture of Klebsiella pneumonia. Anti-Ro/SSA and Anti-nRNP/sm were positive. Intravenous fluid, antibiotic, transfusion of blood, thrombocyte concentrate, and fresh frozen plasma were given. The second baby, male presented with necrotic tissue on the left ear and skin rashes, erythematous macula, athropic scarring, hyperpigmentation on all of his body with various size and facial haemorrhage. He also suffered from thrombocytopenia, mild elevated transaminase enzyme, hyperbilirubinemia, anti-Ro/SSA was positive. Intravenous fluid, methyprednisolone, intravenous immunoglobulin (IVIG), blood, and thrombocyte concentrate transfution were given. Two cases of neonatal lupus erythematous had been presented. Diagnosis based on clinical presentation and maternal auto antibody on neonate. Organ involvement in NLE can occur as single or multiple manifestations.

Keywords: neonatus lupus erythematous, maternal autoantibody, clinical characteristic, multiple organ manifestation

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Authors: Mohamed Salah El-Din Mahmoud, Ahmed Hamed, Asmaa Anwar Mohamed

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Purpose: To study the tear film parameters, total corneal thickness (CT), corneal epithelial thickness and, corneal power in Juvenile systemic lupus erythematosus (JSLE) patients compared to age-matched controls using anterior segment optical coherence tomography (AS-OCT). Methods: This was a cross-sectional study. Study participants were divided into 2 groups: Group A: 75 eyes of JSLE patients, Group B: 75 eyes of healthy controls. Tear meniscus height (TMH), tear meniscus depth (TMD), and tear meniscus area (TMA) were the lower tear meniscus parameters that were measured. The corneal power, CT, and epithelial thickness were all determined automatically. Results: In the JSLE group, the range of age was 10 to 15 years while the control group was 11 to 16 years. TMH, TMA, and TMD were 527.7±46.8, 0.059±0.015 and 343.3±59.9 respectively in JSLE group while 525.4±44.6, 0.058±0.011 and 340.6±58.0 respectively in control group without significant difference (p-value<0.001). The corneal power was 43.3±0.55 in the JSLE while 43.2±0.54 in the control group without significant difference (p-value= 0.407). CT was 551.1±13.5 in JSLE group while 551.2±15.3 in control group without significant difference (p-value= 0.982). Epithelial thickness was 52.66±1.35 in the JSLE group while 52.60±1.36 in the control group without significant difference (p-value= 0.765). Conclusion: We demonstrated no significant difference in tear meniscus dimensions, CT, epithelial thickness, and corneal power in the JSLE patients compared to age-matched controls using AS-OCT.

Keywords: tear film, ASOCT, JSLE, pachymetry, corneal thickness

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Authors: Nirali Sanghavi, Julia Ash, Amy Wasserman

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Introduction: To the best of our knowledge, there is only one case report that found an association between leuprolide and scleroderma renal crisis (SRC). Leuprolide has been noted to cause acute renal failure in some patients. Given the close timing of the leuprolide injection and the worsening renal function in our patient, leuprolide likely caused exacerbation of lupus nephritis and SRC. Interestingly, our patient on long-term hydroxychloroquine (HCQ) with normal baseline cardiac function was found to have HCQ cardiomyopathy highlighting the need for close monitoring of HCQ toxicity. We know that some of the risk factors that are involved in HCQ induced cardiomyopathy are older age, females, increased dose and >10 years of HCQ use, and pre-existing cardiac and renal insufficiency. Case presentation: A 34-year-old African American woman with a history of overlap of systemic lupus erythematosus (SLE) and scleroderma features and class III lupus nephritis presented with severe headaches, elevated blood pressure (180/120 mmHg) and worsening creatinine levels (2.07 mg/dL). The headaches started 1 month ago after she started leuprolide injections for fibroids. She was being treated with mycophenolate mofetil 1 gm twice a day, belimumab weekly, HCQ 200mg, and prednisone 5 mg daily. She has been on HCQ since her teenage years. The examination was unremarkable except for proximal interphalangeal joint contractures in the right hand and sclerodactyly of bilateral hands, unchanged from baseline. Laboratory findings include urinalysis, which showed 3+ protein, 1+ blood, 6 red blood cells, and 14 white blood cells ruling out thrombotic microangiopathy. C3 was 32 mg/dL, C4 <5 mg/dL, and +dsDNA increased >1000. She was started on captopril and discharged once creatinine and blood pressure was controlled. She was readmitted with hypertension, hyperkalemia, worsening creatinine, nephrotic range proteinuria, complaints of chest pressure, and shortness of breath with pleuritic chest pain. Physical examination and lab findings were unchanged. She was treated with pulse dose methyl prednisone followed by taper and multiple anti-hypertensive agents, including captopril, for presumed lupus nephritis flare versus SRC. Renal biopsy was consistent with SRC and class IV lupus nephritis and was started on cyclophosphamide. While cardiac biopsy showed borderline myocarditis without necrosis and cytoplasmic vacuolization consistent with HCQ cardiomyopathy, hence HCQ was discontinued. Summary: It highlights a rare association of leuprolide causing exacerbation of lupus nephritis or SRC. Although rare, the current case reinforces the importance of close monitoring for HCQ toxicity in patients with renal insufficiency.

Keywords: leuprolide, lupus nephritis, scleroderma, SLE

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Authors: Soumaya Mrabet, Taieb Ach, Imen Akkari, Amira Atig, Neirouz Ghannouchi, Koussay Ach, Elhem Ben Jazia

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Introduction: Celiac disease (CD) is an immune-mediated small intestinal disorder that occurs in genetically susceptible people. It is significantly associated with other autoimmune disorders represented mainly by type 1 diabetes and autoimmune dysthyroidism. The aim of our study is to determine the prevalence and the type of the various autoimmune diseases associated with CD in adult patients. Material and methods: This is a retrospective study including patients diagnosed with CD, explored in Internal Medicine, Gastroenterology and Endocrinology and Diabetology Departments of the Farhat Hached University Hospital, between January 2005 and January 2016. The diagnosis of CD was confirmed by serological tests and duodenal biopsy. The screening of autoimmune diseases was based on physical examination, biological and serological tests. Results: Sixty five patients with a female predominance were included, 48women (73.8%) and 17 men (26.2%). The mean age was 31.8 years (17-75). A family history of CD or other autoimmune diseases was present in 5 and 10 patients respectively. Clinical presentation of CD was made by recurrent abdominal pain in 49 cases, diarrhea in 29 cases, bloating in 17 cases, constipation in 25 cases and vomiting in 8 cases. Autoimmune diseases associated with CD were found in 30 cases (46.1%): type 1 diabetes in 15 patients attested by the positivity of anti-GAD antibodies in 11 cases and anti-IA2 in 4 cases, Hashimoto thyroiditis in 8 cases confirmed by the positivity of anti-TPO antibodies, Addison's disease in 2 patients, Anemia of Biermer in 2 patients, autoimmune hepatitis, Systemic erythematosus lupus, Gougerot Sjögren syndrome, rheumatoid arthritis, Vitiligo and antiphospholipid syndrome in one patient each. CD was associated with more than one autoimmune disease defining multiple autoimmune syndrome in 2 female patients. The first patient had Basedow disease, Addison disease and type 1 diabetes. The second patient had systemic erythematosus lupus and Gougerot Sjögren syndrome. Conclusion: In our study autoimmune diseases were associated with CD in 46.1% of cases and were dominated by diabetes and dysthroidism. After establishing the diagnosis of CD the search of associated autoimmune diseases is necessary in order to avoid any therapeutic delay which can alter the prognosis of the patient.

Keywords: association, autoimmune thyroiditis, celiac disease, diabetes

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Authors: Yulmaida Amir, Fahrul Rozi, Insany C. Kamil, Fanny Aryani

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ODAPUS (Orang dengan Lupus) is an Indonesian term for people with Lupus, a chronic autoimmune disease in which immune system of the body becomes hyperactive and attacks normal tissue. The number of ODAPUS indicate an increase in Indonesia, thereby helping to improve their quality of life to be important to help their recovery. This study aims to examine the effect of resilience, self-esteem, and social support on the quality of life of women who had been diagnosed as having Lupus. Data were collected from 64 ODAPUS in Indonesia, using the World Health Organization Quality of Life (WHOQOL), Resilience Scale from Wagnil and Young (1993), self-esteem scale (developed from Coopersmith’s theory), and Social Support Questioner from Northouse (1988). Regression data analysis showed that resilience, social support, and self-esteem predict the quality of life of the ODAPUS simultaneously. If the variable was analysed individually, self-esteem did not significantly contribute to the quality of life. Resilience contributed most significantly to the quality of life, followed by social support. Of five sources of social supports included in the research, support from family members (parents and brother/sisters) has the most significant contribution to the quality of life, followed by support from spouse, and from friends. Interestingly, social support from medical personnel (medical doctors and nurses) had not a significant contribution to the quality of life of ODAPUS. As a conclusion, this research showed that the ability of ODAPUS to cope with difficulty in life, and support from family members, spouse, and friends were the significant predictors for their quality of life.

Keywords: quality of life, resilience, self-esteem, social supports

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Authors: Rene A. Amadore Jr., Ramar John Bangayan, Therese Eileen L. Natividad

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This is a case of a 59-year-old female who presented with a two-year history of heliotrope rash, Gottron's papules, shawl sign, V-neck sign, and muscle weakness. She was previously managed as a case of systemic lupus erythematosus, who initially responded to unrecalled corticosteroids. She was, however, admitted due to a one-month progressively enlarging sacral mass, which eventually turned out to be an abscess. While the abscess was being treated, her autoimmune condition was worked up, and she was then managed as a case of clinically amyopathic dermatomyositis (CADM) with interstitial lung disease (ILD). She received corticosteroids and underwent the first cycle of cyclophosphamide infusion prior to discharge.

Keywords: clinically amyopathic dermatomyositis, interstitial lung disease, corticosteroids, sacral abscess

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Authors: Maximo Cozzetti

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The aim is to evaluate the capability of the 'Siberian Husky' (FCI-Standard Nº 270) breed of the common dog (Canis lupus familiaris) to detect terminally-ill human patients undergoing palliative care. A total of 49 such patients that fulfill the 'National Scientific and Technical Research Council–Ethical Principles for the Behavior of the Scientific and Technical Investigator' policy, (mainly affected with Stage IV Hodgkin lymphoma or Stage IV Carcinoma, though various other terminal diseases were present) and 49 controls were enrolled. A total of 13 specimens of Siberian Huskies (Canis lupus familiaris FCI – Standard Nº 270) were selected. After a conditioning training regime in which the canines were rewarded when identifying terminally ill patients and excluding the control subjects, a double-blind experiment was conducted in which the canines were presented with a previously unknown patient through an olfactory-proof plexiglass window for 2-minute intervals. The test subjects correctly identified 89.80% of the humans as either ‘ill’ or ‘healthy’. It is important to note that both groups of humans were selected considering and preventing confounding and self-identifying factors such as age, ethnicity, clothing, posture, skin color, alopecia (chemotherapy-induced or otherwise), etc. The olfactory-proofing of the test area rules out the use of the sense of smell to detect distinctive drugs or bodily odors that may be associated with terminal diseases. Thus, the Siberian Husky breed of the common dog shows the visual capability to detect and identify terminally ill patients undergoing palliative care regardless of age, posture, and quantity of hair. Though the capability of the breed of dog to detect terminally-ill patients was observed thoroughly during the course of the experiments, the exact process by which the canines identify the test subjects remains unknown and further research is encouraged.

Keywords: Canis lupus familiaris, Siberian Husky, visual identification of terminall illness, FCI-Standard Nº270

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Authors: Zidane Abderrezzaq

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In contrast to recent successful developments in macro monetary policies, the modelling, measurement and management of systemic financial stability has remained problematical. Indeed, the focus of most effort has been on improving individual, rather than systemic, bank risk management; the Basel II objective has been to bring regulatory bank capital into line with the (sophisticated) banks’ assessment of their own economic capital. Even at the individual bank level there are concerns over appropriate diversification allowances, differing objectives of banks and regulators, the need for a buffer over regulatory minima, and the distinction between expected and unexpected losses (EL and UL). At the systemic level the quite complex and prescriptive content of Basel II raises dangers of ‘endogenous risk’ and procyclicality. Simulations suggest that this latter could be a serious problem. In an extension to the main analysis we study how liquidity effects interact with banking structure to produce a greater chance of systemic breakdown. We finally consider how the risk of contagion might depend on the degree of asymmetry (tiering) inherent in the structure of the banking system. A number of our results have important implications for public policy, which this paper also draws out.

Keywords: systemic stability, financial regulation, credit risk, systemic risk

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Authors: Nuhi Arslani, Stojan Potrc, Timotej Mikuljan

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Background: In Department of Abdominal and General Surgery of University Medical Centre Maribor, we treated 578 patients for rectal cancer between 2004 and 2014. During and after treatment we especially concentrated on monitoring local and systemic complications. Methods: For analysis, we used data gathered from preoperative diagnostic tests, reports gathered during operation, reports from the pathohistologic review, and reports on complications after surgery and follow up. Results: In the case of 573 (out of 578) patients (99.1%) we performed resection. R0 was achieved in 551 patients (96,1%). R1 was achieved in 8 patients (1,4%). R2 was achieved in 14 patients (2,4%). Local complications were reported in 78 (13.5%) patients and systemic complications were reported in 68 (11.7%). We would like to point out the low number of local and systemic complications. Conclusions: With advances in surgical techniques, with a multimodal-multidisciplinary approach and with the use of total mesorectal excision we experienced a significant improvement in reducing the number of local and systemic complications in patients with rectal cancer. However, there still remains the question for truly optimal care for each patient with rectal cancer and his quality of life after surgical treatment.

Keywords: local complications, rectal cancer, resection, systemic complications

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Authors: Nader Habibzadeh

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Developing effective and well-targeted conservation strategies is dependent upon fully understanding the complexities of the local situation. We attempted to discern the main likely wolf-human conflict contributing variables in households of Shabestar county’s villages. Data were collected through questions in 53 semi-structured interviews in 36 villages across Shabestar district in summer 2014. The results suggested that people who have reportedly suffered livestock depredation and who have alternative income sources to livestock, are likely to be particularly hostile toward wildlife. With rapid assessment of households using these few key variables we are able to identify likely conflict hotspots and target conflict resolution efforts in those villages. Based on these results, the most important initial strategies for reducing conflict would be reducing the number of livestock killed by wolf, increasing opportunities to generate income only from livestock holdings rather than alternative income sources.

Keywords: human-wildlife conflict, wolf (Canis lupus), Shabestar, Iran

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Authors: Frank Hespeler, Giuseppe Loiacono

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We propose measures for systemic risk generated through intra-sectorial interdependencies in the hedge fund sector. These measures are based on variations in the average cross-effects of funds showing significant interdependency between their individual returns and the moments of the sector’s return distribution. The proposed measures display a high ability to identify periods of financial distress, are robust to modifications in the underlying econometric model and are consistent with intuitive interpretation of the results.

Keywords: hedge funds, systemic risk, vector autoregressive model, risk monitoring

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Authors: A. M. Bumbea, A. Musetescu, P. Ciurea, A. Bighea

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Objectives: The authors present a Parsonage Turner syndrome, a rare disease characterized by onset in apparently healthy person with shoulder and/or arm pain, sensory deficit, motor deficit. The causes are not established, could be determinate by vaccination, postoperative, immunologic disease, post traumatic etc. Methods: The authors present a woman case, 32 years old, (in 2006), no medical history, with arm pain and no other symptom. The onset was sudden with pain at very high level quantified as 10 to a 0 to 10 scale, with no response to classical analgesic and corticoids. The only drugs which can reduce the intensity of pain were oxycodone hydrochloride, 60 mg daily and pregabalinum150 mg daily. After two weeks the intensity of pain was reduced to 5. The patient started a rehabilitation program. After 6 weeks the patient associated sensory and motor deficit. We performed electromyography for upper limb that showed incomplete denervation with reduced neural transmission speed. The patient receives neurotrophic drugs and painkillers for a long period and physical and kinetic therapy. After 6 months the pain was reduced to level 2 and the patient maintained only 150 mg pregabalinum for another 6 months. Then, the evaluation showed no pain but general amiotrophy in upper limb. Results: At the evaluation in 2009, the patient developed a rheumatoid syndrome with tender and swelling joints, but no positive inflammation test, no antibodies or rheumatoid factor. After two years, in 2011 the patient develops an increase of antinuclear antibodies. This context certifies the diagnosis of lupus and the patient receives the specific therapy. Conclusions: This case is not a typical case of onset of lupus with PTS, but the onset of PTS could include the onset of an immune disease.

Keywords: lupus, arm pain, patient, swelling

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Authors: Wassamon Kun-Amornpong

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When a financial crisis occurs, there will be a law and regulatory reform in order to manage the turmoil and prevent a future crisis. One of the most important regulatory efforts to help cope with systemic risk and a financial crisis is the third version of the Basel Accord. Basel III has introduced some measures and tools (e.g., systemic risk buffer, countercyclical buffer, capital conservation buffer and liquidity risk) in order to mitigate systemic risk. Nevertheless, the effectiveness of these measures in Basel III in adequately addressing the problem of contagious runs that can quickly spread throughout the financial system is questionable. This paper seeks to contribute to the knowledge regarding the role of the Basel Accords in mitigating systemic risk. The research question is to what extent the Basel Accords can help control systemic risk in the financial markets? The paper tackles this question by analysing the concept of systemic risk. It will then examine the weaknesses of the Basel Accords before and after the Global financial crisis in 2008. Finally, it will suggest some possible solutions in order to improve the Basel Accord. The rationale of the study is the fact that academic works on systemic risk and financial crises are largely studied from economic or financial perspective. There is comparatively little research from the legal and regulatory perspective. The finding of the paper is that there are some problems in all of the three pillars of the Basel Accords. With regards to Pillar I, the risk model is excessively complex while the benefits of its complexity are doubtful. Concerning Pillar II, the effectiveness of the risk-based supervision in preventing systemic risk still depends largely upon its design and implementation. Factors such as organizational culture of the regulator and the political context within which the risk-based supervision operates might be a barrier against the success of Pillar II. Meanwhile, Pillar III could not provide adequate market discipline as market participants do not always act in a rational way. In addition, the too-big-to-fail perception reduced the incentives of the market participants to monitor risks. There has been some development in resolution measure (e.g. TLAC and MREL) which might potentially help strengthen the incentive of the market participants to monitor risks. However, those measures have some weaknesses. The paper argues that if the weaknesses in the three pillars are resolved, it can be expected that the Basel Accord could contribute to the mitigation of systemic risk in a more significant way in the future.

Keywords: Basel accords, financial regulation, risk-based supervision, systemic risk

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Authors: C. V. Pietreanu, S. E. Zaharia, C. Dinu

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The present research is built on three major pillars, commencing by making some considerations on accident investigation methods and pointing out both defining aspects and differences between linear and non-linear analysis. The traditional linear focus on accident analysis describes accidents as a sequence of events, while the latest systemic models outline interdependencies between different factors and define the processes evolution related to a specific (normal) situation. Linear and non-linear accident analysis methods have specific limitations, so the second point of interest is mirrored by the aim to discover the drawbacks of systemic models which becomes a starting point for developing new directions to identify risks or data closer to the cause of incidents/accidents. Since communication represents a critical issue in the interaction of human factor and has been proved to be the answer of the problems made by possible breakdowns in different communication procedures, from this focus point, on the third pylon a new error-modeling instrument suitable for risk assessment/accident analysis will be elaborated.

Keywords: accident analysis, multi-factorial error modeling, risk, systemic methods

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Authors: Nurvita Wijayanti

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The movie titled The King’s Speech is based on a true story telling an English king suffers from stuttering and how he gets the treatment from the therapist, so that he can reduce the high frequency on stuttering. The treatment uses the unique approach implying the linguistic principles. This study shows how the language works significantly in order to treat the stuttering sufferer using psychological approach. Therefore, the linguistic study is done to analyze the treatment activity. Halliday’s Systemic Functional Grammar is used as the main approach in this study along with qualitative descriptive method. The study finds that the therapist though using the orthodox approach applies the psycholinguistic method to overcome the king’s stuttering.

Keywords: psycholinguistics, stuttering, systemic functional grammar, treatment

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Authors: Emir H. Pernet, Jeimy J. Cano

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Maturity models, used descriptively to explain changes in reality or normatively to guide managers to make interventions to make organizations more effective and efficient, are based on the principles of statistical quality control promulgated by Shewhart in the years 30, and on the principles of PDCA continuous improvement (Plan, Do, Check, Act) developed by Deming and Juran. Some frameworks developed over the concept of maturity models includes COBIT, CMM, and ITIL. This paper presents some limitations of traditional maturity models, most of them based on points of reflection and analysis done by some authors. Almost all limitations are related to the mechanistic and reductionist approach of the principles over those models are built. As Systems Theory helps the understanding of the dynamics of organizations and organizational change, the development of a systemic maturity model can help to overcome some of those limitations. This document proposes a systemic maturity model, based on a systemic conceptualization of organizations, focused on the study of the functioning of the parties, the relationships among them, and their behavior as a whole. The concept of maturity from the system theory perspective is conceptually defined as an emergent property of the organization, which arises from as a result of the degree of alignment and integration of their processes. This concept is operationalized through a systemic function that measures the maturity of an organization, and finally validated by the measuring of maturity in organizations. For its operationalization and validation, the model was applied to measure the maturity of organizational Governance, Risk and Compliance (GRC) processes.

Keywords: GRC, maturity model, systems theory, viable system model

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Authors: Jadwiga Królikowska, Andrzej Królikowski, Jarosław Bajer

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The work delineates the threats of maladjustment of the capacity of rain canals, designed and built in the early 20th century, in connection to heavy rainfall, especially in summer. This is the cause of the so called 'urban floods.' It directly relates to fierce raise of paving in the cities. Resolving this problem requires a change in philosophy of draining the rainfall by wider use of retention, infiltration and usage of rainwater. In systemic approach to managing the safety of urban drainage systems the risk, which is directly connected to safety failures, has been accepted as a measure. The risk level defines the probability of occurrence of losses grater than the ones forecast for a given time frame. The procedure of risk modelling, enabling its numeric analysis by using appropriate weights, is a significant issue in this paper.

Keywords: drainage system, urban areas, risk measurement, systemic approach

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Authors: Sadiq Aminu, Ahmed Lamido

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This research studies Barack Obama’s second inaugural speech using Halliday’s Systemic Functional Grammar (SFG). SFG is a text grammar which describes how language is used, so that the meaning of the text can be better understood. The primary source of data in this research work is Barack Obama’s second inaugural speech which was obtained from the internet. The analysis of the speech was based on the ideational and textual metafunctions of Systemic Functional Grammar. Specifically, the researcher analyses the Process Types and Participants (ideational) and the Theme/Rheme (textual). It was found that material process (process of doing) was the most frequently used ‘Process type’ and ‘We’ which refers to the people of America was the frequently used ‘Theme’. Application of the SFG theory, therefore, gives a better meaning to Barack Obama’s speech.

Keywords: ideational, metafunction, rheme, textual, theme

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Authors: Sujesh F. Sujan, Steve W. Jones, Arto Kiviniemi

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The use of Building Information Modelling (BIM) in the Architectural-Engineering-Construction (AEC) industry is a form of systemic innovation. Unlike incremental innovation, (such as the technological development of CAD from hand based drawings to 2D electronically printed drawings) any form of systemic innovation in Project-Based Inter-Organisational Networks requires complete collaboration and results in numerous benefits if adopted and utilised properly. Proper use of BIM involves people collaborating with the use of interoperable BIM compliant tools. The AEC industry globally has been known for its adversarial and fragmented nature where firms take advantage of one another to increase their own profitability. Due to the industry’s nature, getting people to collaborate by unifying their goals is critical to successful BIM adoption. However, this form of innovation is often being forced artificially in the old ways of working which do not suit collaboration. This may be one of the reasons for its low global use even though the technology was developed more than 20 years ago. Therefore, there is a need to develop a metric/method to support and allow industry players to gain confidence in their investment into BIM software and workflow methods. This paper departs from defining systemic risk as a risk that affects all the project participants at a given stage of a project and defines categories of systemic risks. The need to generalise is to allow method applicability to any industry where the category will be the same, but the example of the risk will depend on the industry the study is done in. The method proposed seeks to use individual perception of an example of systemic risk as a key parameter. The significance of this study lies in relating the variance of individual perception of systemic risk to how much the team is collaborating. The method bases its notions on the claim that a more unified range of individual perceptions would mean a higher probability that the team is collaborating better. Since contracts and procurement devise how a project team operates, the method could also break the methodological barrier of highly subjective findings that case studies inflict, which has limited the possibility of generalising between global industries. Since human nature applies in all industries, the authors’ intuition is that perception can be a valuable parameter to study collaboration which is essential especially in projects that utilise systemic innovation such as BIM.

Keywords: building information modelling, perception of risk, systemic innovation, team collaboration

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