Objective To determine the effect of perioperative blocker treatment in patients having non-cardiac surgery. Design Systematic review and meta-analysis. Data sources Seven search strategies, including searching two bibliographic databases and hand searching seven medical journals. Study selection and outcomes We included randomised controlled trials that evaluated blocker treatment in patients having non-cardiac surgery. Perioperative outcomes within 30 days of surgery included total mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal cardiac arrest, non-fatal stroke, congestive heart failure, hypotension needing treatment, bradycardia needing treatment, and bronchospasm. Results Twenty two trials that randomised a total of 2437 patients met the eligibility criteria. Perioperative blockers did not show any statistically significant beneficial effects on any of the individual outcomes and the only nominally statistically significant beneficial relative risk was 0.44 (95% confidence interval 0.20 to 0.97, 99% confidence interval 0.16 to 1.24) for the composite outcome of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal cardiac arrest. Methods adapted from formal interim monitoring boundaries applied to cumulative meta-analysis showed that the evidence failed, by a considerable degree, to meet standards for forgoing additional studies. The individual safety outcomes in patients treated with perioperative blockers showed a relative risk for bradycardia needing treatment of 2.27 (95% CI 1.53 to 3.36, 99% CI 1.36 to 3.80) and a nominally statistically significant relative risk for hypotension needing treatment of 1.27 (95% CI 1.04 to 1.56, 99% CI 0.97 to 1.66). Conclusion The evidence that perioperative blockers reduce major cardiovascular events is encouraging but too unreliable to allow definitive conclusions to be drawn.

Objective. Spondylarthritides (SpA), including ankylosing spondylitis (AS), are common inflammatory rheumatic diseases that are strongly associated with positivity for the HLA class I allotype B27. HLA-B27 normally forms complexes with ␤ 2 -microglobulin (␤ 2 m) and peptide to form heterotrimers. However, an unusual characteristic of HLA-B27 is its ability to form ␤ 2 m-free heavy chain homodimers (HLA-B27 2 ), which, unlike classic HLA-B27, bind to killer cell immunoglobulinlike receptor 3DL2 (KIR-3DL2). Binding of HLA-B27 2 to KIR-3DL2-positive CD4؉ T and natural killer (NK) cells stimulates cell survival and modulates cytokine production. This study was undertaken to produce an antibody to HLA-B27 2 in order to confirm its expression in SpA and to inhibit its proinflammatory properties.Methods. We generated monoclonal antibodies by screening a human phage display library positively against B27 2 and negatively against B27 heterotrimers. Conclusion. These results demonstrate that antibody HD6 has potential for use in both the investigation and the treatment of AS and other B27-associated spondylarthritides.Positivity for HLA-B27 is strongly associated with ankylosing spondylitis (AS) and other spondylarthritides (SpA) (1-3). However, despite extensive investigation, understanding of the pathogenic role of HLA-B27 is limited (4). The canonical HLA-B27 heterotrimer structure comprises an HLA heavy chain that is noncovalently associated with a monomorphic ␤ 2 -microglobulin (␤ 2 m) light chain and a short peptide derived from self proteins, viruses, or bacteria. These heterotrimeric complexes form in the endoplasmic reticulum and egress to the cell surface, where they are recognized by CD8ϩ cytotoxic T cells through their T cell receptors (5). HLA-B27 can also form ␤ 2 m-free

Possession of HLA-B27 (B27), strongly predisposes to the development of spondyloarthritis. B27 forms classical heterotrimeric complexes with beta-2-microglobulin (β2m) and peptide, and (β2m–free) free H chain (FHC) forms including B27 dimers (termed B272) at the cell surface. In this study we characterise the interaction of HLA-B27 with LILR, leukocyte Ig-like receptor (LILR)B1 and LILRB2 biophysically, biochemically and by FACS staining. LILRB1 bound to B27 heterotrimers with a KD of 5.3 ±1.5 μM but did not bind B27 FHC. LILRB2 bound to B272 and B27 FHC and B27 heterotrimers with KDs of 2.5, 2.6 and 22 ±6μM respectively. Domain exchange experiments showed that B272 bound to the two membrane distal Ig-like domains of LILRB2. In FACS staining experiments, B27 dimer protein and tetramers stained LILRB2 transfectants five times more strongly than B27 heterotrimers. Moreover, LILRB2Fc bound to dimeric and other B27 FHC forms on B27-expressing cell lines more strongly than other HLA-class I FHCs. B27 transfected cells expressing B27 dimers and FHC inhibited IL-2 production by LILRB2-expressing reporter cells to a greater extent than control HLA-class I transfectants. B27 heterotrimers complexed with the L6M variant of the GAG KK10 epitope bound with a similar affinity to complexes with the wild-type KK10 epitope (with KDs of 15.0±0.8 μM and 16.0±2.0 μM respectively). Disulfide-dependent B27 H chain dimers and multimers are stronger ligands for LILRB2 than HLA-class I heterotrimers and H chains. The stronger interaction of B27 dimers and FHC forms with LILRB2 compared with other HLA class I could play a role in spondyloarthritis pathogenesis.