Like his mentor, Howard Levy of the Flecktones, del Junco is capable of playing chromatically on a standard blues-style harmonica. For the musically unschooled, this means that he can play all the notes on an instrument that was designed to play just some of them. Fortunately for us he uses this facility for good rather than evil, in the form of tastefully melodic solos--like the one on "Let's Mambo," a tune that celebrates the land of his ancestors. He is one of those rare musicians whose ideas are completely unhampered by the limitations of the instrument and, more crucial, whose ideas are unceasingly interesting.
Fox, Charles E. Wade, Mitchell J. Cohen, Martin Schreiber , Louis H.
Bulger, Bryan A. Myers, Herb A. Phelan, Christopher E. White, Jiajie Zhang, Mohammad H. Design: Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes.
Data were analyzed using timedependent proportional hazards models. Setting: Ten US level I trauma centers. Main Outcome Measure: In-hospital mortality.
The prospective, observational, multicenter, major trauma transfusion PROMMTT study : Comparative effectiveness of a time-varying treatment with competing risks. Because mRSSs were available for all patients, analysis for associations between mRSS and autoantibodies was performed in patients. An analysis of association between LoSCAT scores and presence of autoantibodies was performed in patients enrolled from forward.
SAS version 9. Of patients in the registry, 64 were excluded because they did not meet inclusion criteria, leaving patients for analysis.
The details of this process are presented in Figure 1. The demographic features of study patients and controls are provided in detail in Table 2.
In addition to comparing the prevalence of autoantibodies between patients with morphea and controls, the prevalence of autoantibodies between the 3 most common morphea subtypes were compared to determine if an association exists between disease subtypes and a particular autoantibody profile. Linear morphea was the only subtype in which specific autoantibodies were present with a higher frequency. There were no associations seen in patients with generalized or plaque morphea.
Other patterns were infrequently present in patients with morphea, including nucleolar, centromere, and cytoplasmic patterns, and were not more frequently present compared with controls. Serum samples that had ANA present at a cutoff titer of were serially diluted up to a titer of Thirty-six samples had a titer of or greater Figure 2.
This association was not present in other subtypes. There were no significant associations between the tested antibodies with morphea activity. There were 46 of patients who had concomitant autoimmune disorders confirmed by direct examination or review of medical records.
The most common concomitant autoimmune conditions included psoriasis 7 patients , rheumatoid arthritis 7 patients , and Hashimoto thyroiditis 4 patients. The aim of the present study was to determine the prevalence and clinical significance of autoantibodies in morphea via a prospective case-control study of the MAC cohort. Similar to prior reports, ANAs were present with greater frequency in patients with morphea than in controls. However, ANAs were not associated with a particular morphea subtype. In addition, AHAs were present with greater frequency in morphea than in controls and were associated specifically with the linear subtype.
All 3 of these autoantibodies were associated with increased disease severity in linear morphea, but not activity, underscoring their limited clinical utility. The high prevalence of ANAs reported in these 2 studies may be due to referral bias pediatric rheumatology practice may be enhanced with patients positive for ANAs and selection bias not all patients were tested a priori. Furthermore, direct comparison is difficult because the methodology and titer cutoff for determination of a positive result were also different.
Nonetheless, our results confirm that ANAs are present with increased frequency at significant titers in a diverse morphea cohort vs a healthy control population, providing further evidence for the autoimmune underpinnings of morphea. In contrast to prior reports, including our own, 2 in which ANAs were more frequently present in generalized and linear subtypes, ANAs were not associated with a particular morphea subtype in the present study.
This is likely due to differences in study design. Prior studies were retrospective or only tested for ANAs in a limited number of morphea subtypes. It is likely that patients with more widespread and severe morphea eg, generalized morphea were more likely to have had ANA testing than were those with less severe disease, which may account for the previously reported association of ANA with generalized morphea, as reported in our retrospective review. This implies that while ANAs are present with higher frequency in morphea, they are not specific to a particular subtype.
The predominance of speckled ANA pattern at a high titer was unexpected. Furthermore, most of these patients did not have commonly identified extractable nuclear antigens or an association with concomitant autoimmune conditions.
These results raise the question of whether there could be an as-yet unrecognized nuclear antigen to which these serum samples are reacting. Further studies are warranted. To date, the prevalence and clinical utility of ssDNA ab in morphea has been controversial. However, our results indicate that among patients with morphea in general, these autoantibodies are infrequently present, even among the linear subtype cases.
The assayed autoantibodies were of limited clinical significance, with the exception of patients with linear morphea. In patients with linear morphea, presence of ssDNA abs was associated with both extensive BSA and functional limitation, and a positive AHA was associated with extensive BSA, findings that are similar to those of Arkachaisri and colleagues. Our study, while the largest of its kind, is still limited by small sample size, especially with regard to certain morphea subtypes and the relative infrequent presence of the tested autoantibodies.
The same is true of the association between AHAs, ss-DNA abs, and morphea activity because very few patients with morphea had these autoantibodies. Also, some associations fail to retain statistical significance with adjustment for multiple comparisons, specifically the association of AHA and linear subtype, and should be interpreted with caution.
Our results have several implications for practice. There is little indication for repeated testing of these autoantibodies as a marker of disease activity or remission, although longitudinal studies are needed for confirmation. Unfortunately, despite these associations, these antibodies are relatively infrequently present, even among patients with linear morphea.
This underscores the need for studies to identify biomarkers relevant to morphea. Published Online: August 7, Author Contributions: Dr Jacobe had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Critical revision of the manuscript for important intellectual content: Warner Dharamsi, Aguwa, Arnett, Mayes, Jacobe. Conflict of Interest Disclosures: None reported. All Rights Reserved. Figure 1.
Editorial Reviews. About the Author. Ralph Dittman is a retired MD who ran a stem cell The Del Junco Cohort - Kindle edition by Ralph Dittman. Download it . The del junco cohort. Armed with a list love shots sweet short treats for anytime anywhere book 2. The treekeepers. Job satisfaction fact or fiction are you.
View Large Download. Table 1. Juvenile localized scleroderma: clinical and epidemiological features in children: an international study.