Fear of Flying—This clinical anecdote appears regularly in my clinic. So much so that I believe it needs further study. A number of my APS patients, notably before treatment has been started, suffer badly from prolonged jet lag after a long-haul flight, with fatigue, headache and confusion, sometimes lasting for days.
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Interestingly, once heparin or warfarin treatment is successfully commenced, this phenomenon disappears. Whether these symptoms relate to mild cerebral hypoxia second to slightly reduced cabin pressure is not known. Nevertheless, some of my patients with APS will supplement their aspirin treatment prior to a long-haul flight with an injection of LMW heparin. Although the placebo effect may be considerable, I am sufficiently impressed by the clinical experience of these (observant) patients to believe that the phenomenon of prolonged jet lag in many of our patients is very real.
The Future—At the 14th International Congress on Antiphospholipid Antibodies held in Rio de Janeiro in 2013, I was asked for my predictions on the future of APS.23 In summary, I believe:
- aPL testing will become worldwide and routine;
- Over-the-counter aPL testing kits will become available;
- A substantial subset of migraine sufferers will have new hope;
- APS will become recognized as the major link between migraine and stroke;
- Heart attacks in young women (especially those under 45) will be reduced;
- Strokes in those under 45 will be reduced;
- Some cases of accelerated arterial disease will be recognized as being associated with (untreated) aPL;
- Some cases of memory loss are treatable;
- APS will continue to have a profound effect on our clinical assessment and treatment of lupus; and
- Finally, to return to the opening theme, the incidence of stillbirth will be reduced, thanks, in part, to a more proactive approach to aPL testing in pregnancy.
To repeat a sentence taken from the 1983 paper:1
For those of us hardened into nihilism by years of study of various autoantibodies in SLE, there is a rare sense of excitement at the implications of the associations now being reported.
Thirty years on, that clinical excitement remains undimmed.
Graham R.V. Hughes, MD, FRCP, is a consultant rheumatologist and head of the London Lupus Centre. He trained at The London Hospital, and spent two years in New York working on the introduction of the DNA-binding test, under the leadership of Dr. Charles Christian. In 1971, he opened a specialist clinic in London, dealing uniquely with lupus and related diseases. He is founder and editor of the international journal, Lupus. In 1983, he described the antiphospholipid syndrome and in 1991, was awarded the ILAR (world research) prize for this work. Other honors include Doctor Honoris Causa in the Universities of Marseille and Barcelona, and Master of the ACR.
- Hughes GR. Thrombosis, abortion, cerebral disease, and the lupus anticoagulant. Br Med J (Clin Res Ed). 1983 Oct 15;287(6399):1088–1089.
- Harris EN, Gharavi AE, Boey ML, et al. Anticardiolipin in antibodies: Detection by radioimmunoassay and association with thrombosis in SLE. Lancet. 1983 Nov 26;2(8361):1211–1214.
- Boey ML, Colaco CB, Gharavi AE, et al. Thrombosis in SLE: Striking association with the presence of circulating lupus anticoagulant. Br Med J (Clin Res Ed). 1983 Oct 8;287:1021–1023.
- Hughes GR. The Prosser White oration 1983: Connective tissue disease and the skin. Clin Exp Dermatol. 1984 Nov;9(6):535–544.
- Asherson RA, Mackworth-Young CG, Boey ML, Hughes GRV. Pulmonary hypertension in systemic lupus erythematosus. Br Med J (Clin Res Ed). 1983 Oct 8;287(6398):1024–1025.
- Derue GJ, Englert HJ, Harris EN, et al. Fetal loss in systemic lupus: Association with anticardiolipin antibodies. J Obstet Gynaecol. 1985;5(4):207–209.
- Hughes GR, Harris NN, Gharavi AE. The anticardiolipin syndrome. J Rheumatol. 1986 Jun;13(3):486–489.
- Hughes GR. Hughes’ syndrome: The anticardiolipin syndrome. A historical view. Lupus. 1998;7 Suppl 2:S1–S4.
- Carecchio M, Cantello R, Comi C. Revisiting the molecular mechanism in antiphospholipid syndrome: Beyond vascular damage. J Immunol Res. 2014;2014:239398.
- Bluestein HG, Zvaifler NJ. Brain-reactive lymphocytotoxic antibodies in the serum of patients with SLE. J Clin Invest. 1976 Feb;57(2):509–516.
- Bresnihan B, Oliver N, Grigor R, Hughes GR. Brain-reactivity of lymphocytotoxic anitibodies in systemic lupus erythematosus with and without cerebral involvement. Clin Exp Immunol. 1977 Dec;30(3):333–337.
- Bresnihan B, Hohmeister R, Cutting J, et al. The neuropsychiatric disorder in SLE: Evidence for both vascular and immune mechanisms. Ann Rheum Dis. 1979 Aug;38(4):301–306.
- Denburg SD, Behmann SA, Carbotte RM, et al. Lymphocyte antigens in neuropsychiatric systemic lupus erythematosus. Relationship of lymphocyte antibody specificities to clinical disease. Arthritis Rheum. 1994 Mar;37(3):369–375.
- Harris EN, Gharavi AE, Asherson RA, et al. Cerebral infarction in SLE. Association with anticardiolipin antibodies. Clin Exp Rheumatol. 1984 Jan-Mar;2(1):47–51.
- Navarrete MG, Brey RL, Levine SR. “Cerebral disease in the antiphospholipid syndrome” in Hughes Syndrome—Antiphospholipid Syndrome. Khamashta MA, ed. Springer, London: 2000.
- Sanna G, Bertolaccini ML, Cuadrado MJ, et al. Central nervous system involvement in the antiphospholipid (Hughes) syndrome. Rheumatology (Oxford). 2003 Feb;42(2):200–213.
- Etminan M, Takkouche B, Isorna FC, Samii A. Risk of ischaemic stroke in people with migraine: Systemic review and meta-analysis of observational studies. BMJ. 2005 Jan 8;330(7482):63.
- Nencini P, Baruffi MC, Abbate R, et al. Lupus anticoagulant and anticardiolipin antibodies in young adults with cerebral ischaemia. Stroke. 1992 Feb;23(2):189–193.
- Hughes GR. Antiphospholipid syndrome, migraine and stroke. Lupus. 2010 Apr;19(5):555–556.
- Mackworth-Young CG, Hughes GR. Epilepsy: An early symptom of systemic lupus erythematosus. J Neurol Neurosurg Psychiatry. 1985 Feb;48(2):185.
- Cimaz R, Meroni PL, Shoenfeld Y. Epilepsy as part of systemic lupus erythematosus and systemic antiphospholipid syndrome (Hughes syndrome). Lupus. 2006;15(4):191–194.
- Hughes GR. “Diplomatic epilepsy” in Understanding Hughes Syndrome. Springer-Verlag, London: 2009.
- Hughes GR. Hughes syndrome/APS. 30 years on, what have we learnt? Opening talk at the 14th International Congress on antiphospholipid antibodies. Rio de Janeiro, October 2013. Lupus. 2014;23:400–406.
- Cuadrado MJ, Khamashta MA, Ballesteros A, et al. Can neurologic manifestations of Hughes (antiphospholipid) syndrome be distinguished from multiple sclerosis? Analysis of 27 patients and review of the literature. Medicine (Baltimore). 2000 Jan;79(1):57–68.
- Hughes GR. Migraine, memory loss, and “multiple sclerosis.” Neurological features of the antiphospholipid (Hughes’) syndrome. Postgrad Med J. 2003 Feb;79(928):81–83.
- Uthman I, Noureldine MH, Berjawi A, et al. Hughes syndrome and multiple sclerosis. Lupus. 2015 Feb;24(2):115–121.
- Cervera R, Asherson RA, Font J, et al. Chorea in the antiphospholipid syndrome. Clinical, radiologic, and immunologic characteristics of 50 patients from our clinics and the recent literature. Medicine (Baltimore). 1997 May;76(3):203–212.
- Baizabal-Carvallo JF, Bonnet C, Jankovic J. Movement disorders in systemic lupus erythematosus and the antiphospholipid syndrome. J Neural Transm (Vienna). 2013 Nov;120(11):1579–1589.
- Schofield JR, Blitshteyn S, Shoenfeld Y, et al. Postural tachycardia syndrome (POTS) and other autonomic disorders in antiphospholipid (Hughes) syndrome (APS). Lupus. 2014 Jun;23(7):697–702.
- Sangle S, D’Cruz DP, Khamashta MA, et al. Antiphospholipid antibodies, systemic lupus erythematosus, and non-traumatic metatarsal fractures. Ann Rheum Dis. 2004 Oct;63(10):1241–1243.
- Greco TP1, Conti-Kelly AM, Greco T Jr., et al. Newer antiphospholipid antibodies predict adverse outcomes in patients with acute coronary syndrome. Am J Clin Pathol. 2009 Oct;132(4):613–620.
- Urbanus RT, Siegerink B, Roest M, et al. Antiphospholipid antibodies and risk of myocardial infarction and ischaemic stroke in young women in the RATIO study: A case-control study. Lancet Neurol. 2009 Nov;8(11):998–1005.
- Nair S, Khamashta MA, Hughes GR. Syndrome X and Hughes syndrome. Lupus. 2002;11(5):332.
- Sangle SR, Jan W, Lau IS, et al. Coeliac artery stenosis and antiphospholipid (Hughes) syndrome/antiphospholipid antibodies. Clin Exp Rheumatol. 2006 May–Jun;24(3):349.
- Mackworth-Young CG, Melia WM, Harris EN, et al. The Budd-Chiari syndrome. Possible pathogenetic role of anti-phospholipid antibodies. J Hepatol. 1986;3(1):83-86.
- Hanouna G, Morel N, Le Thi Huong D, et al. Catastrophic antiphospholipid syndrome and pregnancy: An experience of 13 cases. Rheumatology (Oxford). 2013 Sep;52(9):1635–1641.
- Sangle SR, D’Cruz DP, Jan W, et al. Renal artery stenosis in antiphospholipid syndrome (Hughes) and hypertension. Ann Rheum Dis. 2003 Oct;62(10):999–1002.
- Englert HJ, Loizou S, Derue GG, et al. Clinical and Immunological features of livedo reticularis in lupus. Am J Med. 1989 Oct;87(4):408–410.
- Sangle SR, D’Cruz DP. Livedo reticularis: An enigma. Isr Med Assoc J. 2015 Feb;17(2):104–107.
- Ateka-Barrutia O, Khamashta MA. The challenge of pregnancy for patients with SLE. Lupus. 2013 Oct;22(12):1295–1308.
- Hughes GR. The stillbirth scandal. Lupus. 2013 Jul;22(8):759–760.
- Silver RM, Parker CB, Reddy UM, et al. Antiphospholipid antibodies in stillbirth. Obstet Gynecol. 2013 Sep;122(3):641–657.
- Rodriguez-Garcia JL, Bertolaccini ML, Cuadrado MJ, et al. Clinical manifestations of antiphospholipid syndrome (APS) with and without antiphospholipid antibodies (the so-called ‘seronegative APS’). Ann Rheum Dis. 2012 Feb;71(2):242–244.
- Meroni PL, Chighizab CB, Rovelli F, et al. Antiphospholipid syndrome in 2014: More clinical manifestations, novel pathogenic players and emerging biomarkers. Arthritis Res Ther. 2014;16(2):209.
- Hughes GR, Khamashta MA. Seronegative antiphospholipid syndrome. Ann Rheum Dis. 2003 Dec;62(12):1127.
- Rodguez-Garcia JL, Bertolaccini ML, Cuadrado MJ, et al. Clinical manifestations of antiphospholipid syndrome (APS) with and without antiphospholipid antibodies. Ann Rheum Dis. 2012 Feb;71(2):242–244.
- Giles I, Khamashta M, D’Cruz D, et al. A new dawn of anticoagulation for patients with antiphospholipid syndrome. Lupus. 2012 Oct;21(12):1263–1265.
- Canuad G, Bienaimé C, Taborin F, et al. Inhibition of the mTORC pathway in the antiphospholipid syndrome. New Eng J Med. 2014 Jul 24;371(4):303–312.
- Hughes GR. Heparin, antiphospholipid antibodies and the brain. Lupus. 2012 Sep;21(10):1039–1040.
- Weissmann G. Queen Anne’s lupus: Phospholipids and the course of the empire. FASEB J. 2014 Apr;28(4):1527–1530.
- Mekinian A, Lachassinne E, Nicaise-Roland P, et al. European registry of babies born to mothers with antiphospholipid syndrome. Ann Rheum Dis. 2013 Feb;72(2):217–222.
- Nalli C, Iodice A, Andreoti L, et al. Children born to SLE and APS mothers. Lupus. 2014 Oct;23(12):1246–1248.
- Major S, Pashayan N, Atweh S, et al. Practice patterns of antiphospholipid syndrome at a tertiary teaching hospital in Lebanon. Lupus. 2002;11(11):759–764.