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Objective: Lupus nephritis (LN) is a major cause of morbidity and mortality, affecting up to 60% of patients with systemic lupus erythematosus (SLE). The perspectives of patients with SLE have been explored; however, little is known of the lived experiences of patients with LN., Methods: Patients aged ≥18 years with biopsy-proven pure or mixed International Society of Nephrology/Renal Pathology Society Class III, IV or V LN were purposefully recruited from a Canadian lupus cohort to participate in a photovoice (visual-narrative participatory research method) exercise. Participants took photos of what LN means to them, impacts on daily life and factors impacting LN management. Photos were shared and discussed in focus groups., Results: 13 individuals with LN participated (92.3% were female; mean (SD) age was 41.7 (14.0) years). The mean (SD) number of photos shared per participant was 4.2 (0.9). Photos (n=54) depicted activities/settings that contribute to well-being (n=15), the participants themselves (n=13), healthcare experiences (n=10), home (n=4), community (n=2), friends (n=2), work (n=2) and other challenges (n=6). All participants described physical and psychosocial impacts of living with LN. Although 12 mentioned activities/settings that contribute to well-being (eg, time in natural environments), participants were consistently reminded of limitations imposed by LN due to physical symptoms, challenges presented by the physical environment and the altered life trajectories experienced. Participants discussed the dual burden of LN and the associated medication journey; side effects and medication-related financial challenges were highlighted by ten and five participants, respectively., Conclusions: Participants reported a substantial psychosocial burden associated with altered life trajectories, the dual burden of LN and the associated medication journey, and the conflicting role of the physical environment. The need for flexibility (ie, from employers, themselves) is an essential component of navigating altered life trajectories., Competing Interests: Competing interests: FSC and SJE have no conflicts of interest to disclose. MRWB has received consulting fees from AbbVie, AstraZeneca, Janssen, GSK and Sanofi-Genzyme. KC has received consulting fees from Novartis and speaker fees from Alexion. SG and AB are employees of GSK. AB also holds stock/shares in GSK. AEC has received grant/research support from GSK, and consulting fees/honoraria from AstraZeneca, Bristol Myers Squibb, GSK, Otsuka and Roche; and holds The Arthritis Society Chair in Rheumatic Diseases at the University of Calgary., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Long-term anticoagulant therapy is generally recommended for thrombotic antiphospholipid syndrome (TAPS) patients, however it may be withdrawn or not introduced in routine practice., Objectives: To prospectively evaluate the risk of thrombosis recurrence and major bleeding in non-anticoagulated TAPS patients, compared to anticoagulated TAPS, and secondly, to identify different features between those two groups., Patients/methods: Using an international registry, we identified non-anticoagulated TAPS patients at baseline, and matched them with anticoagulated TAPS patients based on gender, age, type of previous thrombosis, and associated autoimmune disease. Thrombosis recurrence and major bleeding were prospectively analyzed using Kaplan-Meier method and compared using a marginal Cox's regression model., Results: As of June 2022, 94 (14 %) of the 662 TAPS patients were not anticoagulated; and 93 of them were matched with 181 anticoagulated TAPS patients (median follow-up 5 years [interquartile range 3 to 8]). The 5-year thrombosis recurrence and major bleeding rates were 12 % versus 10 %, and 6 % versus 7 %, respectively (hazard ratio [HR] 1.38, 95 % confidence interval [CI] 0.53 to 3.56, p = 0.50 and HR 0.53; 95 % CI 0.15 to 1.86; p = 0.32, respectively). Non-anticoagulated patients were more likely to receive antiplatelet therapy (p < 0.001), and less likely to have more than one previous thrombosis (p < 0.001) and lupus anticoagulant positivity (p = 0.01)., Conclusion: Fourteen percent of the TAPS patients were not anticoagulated at recruitment. Their recurrent thrombosis risk did not differ compared to matched anticoagulated TAPS patients, supporting the pressing need for risk-stratified secondary thrombosis prevention trials in APS investigating strategies other than anticoagulation., Competing Interests: Declaration of competing interest Authors had no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to understand the impact of the COVID-19 pandemic on inflammatory arthritis (IA) rheumatology care in Alberta, Canada., Methods: We used linked provincial health administrative datasets to establish an incident cohort of individuals with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and Ankylosing Spondylitis (AS) seen at least once by a rheumatologist. We examined incidence rates (IR) per 100,000 population, and patterns of follow-up care between 2011 and 2022. In a subset of individuals diagnosed five years prior to the pandemic, we report on those lost to follow-up during the pandemic, and those with virtual care visits followed by in-person visit within 30 days. Multivariable logistic regression was used to examine patient characteristics associated with these patterns of care., Results: The IR for RA in 2020 declined compared to previous years (44.6), but not for AS (9.2) or PsA (9.1). In 2021 IRs rose (RA 49.5; AS 11.8; PsA 11.8). Among those diagnosed within 5 years of the pandemic, 632 (6.0 %) were lost to follow-up, with characteristics of those lost to follow-up differing between IA types. 1444 individuals had at least one virtual visit followed within 30 days by an in-person follow-up. This was less common in males (OR 0.69-0.79) and more common for those with a higher frequency of physician visits prior to the pandemic (OR 1.27-1.32)., Conclusion: Impacts of patterns of care during the pandemic should be further explored for healthcare planning to uphold optimal care access and promote effective use of virtual care., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest directly related to this work., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: An emerging strategy to address access challenges to rheumatologists for patients with RA is shared care between primary and specialist care, with patient-initiated rheumatologist follow-up as needed. The objective of this scoping review was to explore studies implementing this model of care., Methods: Four electronic databases were searched from 01/01/2000-31/03/2022 using three main concepts (RA, shared care, patient-initiated follow-up). English-language studies of any design were included if they described the implementation and/or outcomes of shared care model for RA with patient-initiated follow-up. Two authors reviewed and selected articles in duplicate and extracted data on study characteristics, care model implementation and outcomes according to a pre-specified protocol., Results: Following duplicate removal, 1578 articles were screened for inclusion and 58 underwent full-text review. Sixteen articles were included, representing 10 unique studies. Five studies had qualitative outcomes and two were pre-implementation studies. Model implementation varied significantly between studies. Effectiveness data was available in 10 studies and demonstrated equivalent outcomes for the model of care (disease activity, radiographic damage, quality of life). Health system costs were equivalent or lower than usual care. While satisfaction with care was equivalent or improved in shared care models with patient-initiated follow-up, some concerns were expressed in qualitative evaluation around appropriate patient selection for such models, and information for health equity evaluation was not reported., Conclusions: While shared care models with patient-initiated follow-up may offer comparable outcomes for RA, further work is required to understand patient preferences, health equity considerations and longer-term outcomes for such models of care., Competing Interests: Declaration of Competing Interest None of the authors have any competing interests to declare., (Copyright © 2023. Published by Elsevier Inc.)

Competing Interests: Intérêts concurrents: Megan Barber est cochercheuse au projet APSACTION (Antiphospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking) et a reçu des honoraires de GSK en tant que modératrice, de même que des honoraires pour sa participation à des comités consultatifs pour Janssen, Sanofi-Genzyme, AstraZeneca et Abbvie. Ann Clarke est membre d’APS-ACTION et fait état d’honoraires versés par AstraZeneca, Bristol Myers Squibb et GSK, de même que d’un financement de recherche de GSK. Leslie Skeith est membre d’APS-ACTION et du Réseau CanVECTOR (Canadian Venous Thromboembolism Research Network) et déclare des honoraires de Leo Pharma et de Sanofi. Aucun autre intérêt n’a été déclaré.

Introduction: Systemic lupus erythematosus (SLE) is characterized by autoantibody expression and aberrant autoreactive B cells contribute to disease progression; therefore, B cell inhibition has been an attractive target for novel therapies. However, after more than two decades of research and over 40 randomized clinical trials, only one such therapy, belimumab, has been approved for use in SLE., Areas Covered: In this review, we discuss the evidence for B cell-targeted therapies in SLE and lupus nephritis. Belimumab has been successful in several large clinical trials and is approved in several countries for use in SLE and lupus nephritis. Despite a lack of supporting phase III evidence, rituximab is used off-label in SLE. Several other B cell-targeted therapies have failed to meet their end points in late-stage clinical trials. Successful phase II trials have recently been reported for obinutuzumab and telitacicept with larger confirmatory trials currently underway., Expert Opinion: Refinements in pharmaceutical mechanisms of action, trial design, and patient selection have resulted in recent preliminary successes, offering renewed optimism for B-cell targeted therapeutics in SLE management.

Competing Interests: Competing interests: Megan Barber is a coinvestigator of Antiphospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS-ACTION) and has received moderator fees from GSK, as well as advisory board fees from Janssen, Sanofi-Genzyme, AstraZeneca and Abbvie. Ann Clarke is a member of APS-ACTION and reports honoraria from AstraZeneca, Bristol Myers Squibb and GSK, as well as research funding from GSK. Leslie Skeith is a member of APS-ACTION and the Canadian Venous Thromboembolism Research Network (CanVECTOR), and reports honoraria from Leo Pharma and Sanofi. No other competing interests were declared.

Introduction: Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death., Areas Covered: This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020., Expert Opinion: Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.

Birds have a smaller repertoire of immune genes than mammals. In our efforts to study antiviral responses to influenza in avian hosts, we have noted key genes that appear to be missing. As a result, we speculate that birds have impaired detection of viruses and intracellular pathogens. Birds are missing TLR8, a detector for single-stranded RNA. Chickens also lack RIG-I, the intracellular detector for single-stranded viral RNA. Riplet, an activator for RIG-I, is also missing in chickens. IRF3, the nuclear activator of interferon-beta in the RIG-I pathway is missing in birds. Downstream of interferon (IFN) signaling, some of the antiviral effectors are missing, including ISG15, and ISG54 and ISG56 (IFITs). Birds have only three antibody isotypes and IgD is missing. Ducks, but not chickens, make an unusual truncated IgY antibody that is missing the Fc fragment. Chickens have an expanded family of LILR leukocyte receptor genes, called CHIR genes, with hundreds of members, including several that encode IgY Fc receptors. Intriguingly, LILR homologues appear to be missing in ducks, including these IgY Fc receptors. The truncated IgY in ducks, and the duplicated IgY receptor genes in chickens may both have resulted from selective pressure by a pathogen on IgY FcR interactions. Birds have a minimal MHC, and the TAP transport and presentation of peptides on MHC class I is constrained, limiting function. Perhaps removing some constraint, ducks appear to lack tapasin, a chaperone involved in loading peptides on MHC class I. Finally, the absence of lymphotoxin-alpha and beta may account for the observed lack of lymph nodes in birds. As illustrated by these examples, the picture that emerges is some impairment of immune response to viruses in birds, either a cause or consequence of the host-pathogen arms race and long evolutionary relationship of birds and RNA viruses., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Ducks can survive infection with highly pathogenic avian influenza viruses that are lethal to chickens. We showed that the influenza detector, RIG-I can initiate antiviral responses in ducks, but this gene is absent in chickens. We can reconstitute this pathway by transfecting chicken DF-1 embryonic fibroblast cells with duck RIG-I, which augments their antiviral response to influenza and decreases viral titer. However, the genes downstream of duck RIG-I that mediate this antiviral response to influenza are not known. Using microarrays, we compared the transcriptional profile of chicken embryonic fibroblasts transfected with duck RIG-I or empty vector, and infected with low or highly pathogenic avian influenza viruses. Transfected duck RIG-I expressed in chicken cells was associated with the marked induction of many antiviral innate immune genes upon infection with both viruses. We used real-time PCR to confirm upregulation of a subset of these antiviral genes including MX1, PKR, IFIT5, OASL, IFNB, and downregulation of the influenza matrix gene. These results provide some insight into the genes induced by duck RIG-I upon influenza infection, and provide evidence that duck RIG-I can function to elicit an interferon-driven, antiviral response against influenza in chicken embryonic fibroblasts., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Ducks are the natural host and reservoir of influenza viruses. We are interested in their immune responses to these viruses, to understand host-pathogen interactions and to develop effective agricultural vaccines. We identified duck homologues of the chemokines CCL19 and CCL21 and cloned their cognate receptor, CCR7. Conservation of key features, and expression in lymphoid tissues suggests that these chemokines are the direct orthologues of their mammalian counterparts. Mammalian CCL19 and CCL21 are responsible for the homing of dendritic cells and naïve lymphocytes to secondary lymphoid tissues. The contribution of local tertiary lymphoid tissues may be important during influenza infection in ducks. Consistent with leukocyte recruitment, CCL19 and CCL21 transcripts are abundant in lung tissues at 1 day post-infection with highly pathogenic avian influenza A/Vietnam/1203/04 (H5N1) (VN1203). In contrast, expression in lung or intestine tissues infected with low pathogenic A/mallard/BC/500/05 (H5N2) (BC500) is not significant. Recruitment and aggregation of leukocytes is visible in the vicinity of major airways 3 days after infection with VN1203. Chemokine gene expression may serve as a useful marker to evaluate duck immune responses to natural infections and vaccine strains., (Copyright © 2011 Elsevier Ltd. All rights reserved.)