Enhancing virus-specific immunity in vivo by combining therapeutic vaccination and PD-L1 blockade in chronic hepadnaviral infection

Hepatitis B virus (HBV) persistence is facilitated by exhaustion of CD8 T cells that express the inhibitory receptor programmed cell death-1 (PD-1). Improvement of the HBV-specific T cell function has been obtained in vitro by inhibiting the PD-1/PD-ligand 1 (PD-L1) interaction. In this study, we examined whether in vivo blockade of the PD-1 pathway enhances virus-specific T cell immunity and leads to the resolution of chronic hepadnaviral infection in the woodchuck model. The woodchuck PD-1 was first cloned, characterized, and its expression patterns on T cells from woodchucks with acute or chronic woodchuck hepatitis virus (WHV) infection were investigated. Woodchucks chronically infected with WHV received a combination therapy with nucleoside analogue entecavir (ETV), therapeutic DNA vaccination and woodchuck PD-L1 antibody treatment. The gain of T cell function and the suppression of WHV replication by this therapy were evaluated. We could show that PD-1 expression on CD8 T cells was correlated with WHV viral loads during WHV infection. ETV treatment significantly decreased PD-1 expression on CD8 T cells in chronic carriers. In vivo blockade of PD-1/PD-L1 pathway on CD8 T cells, in combination with ETV treatment and DNA vaccination, potently enhanced the function of virus-specific T cells. Moreover, the combination therapy potently suppressed WHV replication, leading to sustained immunological control of viral infection, anti-WHs antibody development and complete viral clearance in some woodchucks. Our results provide a new approach to improve T cell function in chronic hepatitis B infection, which may be used to design new immunotherapeutic strategies in patients.

Chronic hepatitis B virus (HBV) infection is still one of the major public health problems. Two billion people worldwide have been infected with HBV, of whom more than 360 million developed chronic infection. Every year, approximately one million of these individuals will die from HBV-associated liver diseases such as cirrhosis and hepatocellular carcinoma (HCC). Treatment of chronic hepatitis B remains a clinical challenge, and alternative strategies to treat chronic HBV infection are urgently needed. Here, we designed a new combination strategy to enhance the patient's own antiviral immune response and to achieve long-term viral suppression. The therapeutic effect of our combination therapy strategy for chronic hepadnaviral infection was tested in the woodchuck model. We demonstrated that our novel combination therapy could elicit potent antiviral immune response and achieved a strong antiviral effect, leading to sustained immunological control of chronic hepadnaviral infection and complete viral clearance in treated woodchucks. The results of this study may have an impact on clinical trials of the immunotherapy in chronically HBV-infected patients.

TERT promoter mutations are frequent in cutaneous basal cell carcinoma and squamous cell carcinoma

Activating mutations in the TERT promoter were recently identified in up to 71% of cutaneous melanoma. Subsequent studies found TERT promoter mutations in a wide array of other major human cancers. TERT promoter mutations lead to increased expression of telomerase, which maintains telomere length and genomic stability, thereby allowing cancer cells to continuously divide, avoiding senescence or apoptosis. TERT promoter mutations in cutaneous melanoma often show UV-signatures. Non-melanoma skin cancer, including basal cell carcinoma and squamous cell carcinoma, are very frequent malignancies in individuals of European descent. We investigated the presence of TERT promoter mutations in 32 basal cell carcinomas and 34 cutaneous squamous cell carcinomas using conventional Sanger sequencing. TERT promoter mutations were identified in 18 (56%) basal cell carcinomas and in 17 (50%) cutaneous squamous cell carcinomas. The recurrent mutations identified in our cohort were identical to those previously described in cutaneous melanoma, and showed a UV-signature (C>T or CC>TT) in line with a causative role for UV exposure in these common cutaneous malignancies. Our study shows that TERT promoter mutations with UV-signatures are frequent in non-melanoma skin cancer, being present in around 50% of basal and squamous cell carcinomas and suggests that increased expression of telomerase plays an important role in the pathogenesis of these tumors.

EFSUMB minimum training requirements for rheumatologists performing musculoskeletal ultrasound

In order to optimize and standardize musculoskeletal ultrasonography education for rheumatologists, there is a need for competency assessments addressing the required training and practical and theoretical skills. This paper describes how these competency assessments for rheumatologists were developed and what they contain.

Which knee and probe position determines the final diagnosis of knee inflammation by ultrasound? Results from a European multicenter study

PURPOSE

To investigate which knee and probe position best identifies knee inflammation and to determine a cut-off level for abnormal synovial effusion.

MATERIALS AND METHODS

18 experienced sonographers (all rheumatologists) performed ultrasound examinations of the knee joint in patients with knee symptoms and in healthy controls. Each sonographer performed longitudinal suprapatellar ultrasound scans using 9 different configurations at each knee: Midline, parapatallar lateral and parapatellar medial from midline in neutral position (0°) with and without quadriceps muscle contraction and in 30° flexion of the knee. The presence of synovial effusion (SE), the effusion measured in millimeters and the presence of synovial hypertrophy (SH) was noted.

RESULTS

A total of 298 knees of 149 subjects (129 patients and 20 controls) were examined. The detection of SH is more sensitive and specific than the detection of SE, independently of the knee and probe position, for the final diagnosis of abnormality. The detection of both synovial hypertrophy and effusion in the knee in neutral position (0°) with quadriceps contraction and with the probe in the midline position, are the best independent predictors for knee abnormalities. Knee effusion > 3.2 mm measured with the probe in the lateral aspect of the knee is the best diagnostic characteristics for predicting pathological SE.

CONCLUSION

The best combination for detecting SH and SE is obtained by placing the probe in the midline position with the knee in 0° with quadriceps contraction. A cut-off value for pathological effusion may be obtained in the lateral aspect of the knee.

Ultrasound evaluation of fluid in knee recesses at varying degrees of flexion

OBJECTIVE

Various methods are utilized in daily practice to obtain optimal information on effusion in the knee. Our aim is to investigate which scanning position provides the best information about synovial fluid in the knee by using ultrasound and to evaluate the magnitude of difference for measuring synovial fluid in 3 major recesses (suprapatellar, medial parapatellar, and lateral parapatellar) of the knee according to various degrees of flexion.

METHODS

Sonographers in 14 European centers documented bilateral knee joint ultrasound examinations on a total of 148 knee joints. The largest sagittal diameter of fluid was measured in scans corresponding to the 3 major recesses at different (0°, 15°, 30°, 45°, 60°, and 90°) degrees of flexion of the knee. The difference of measurement of effusion according to transducer position, knee position, and the interaction between them was investigated by analysis of variance followed by Tukey's test.

RESULTS

No correlation was noted between patient characteristics and ultrasound detection of effusion. The sagittal diameter of synovial fluid in all 3 recesses was greatest at 30° flexion. Analysis of variance and Tukey's test revealed that the suprapatellar scan and 30° flexion is the best combination for detecting effusion as confirmed by receiver operator characteristic curve analysis.

CONCLUSION

The suprapatellar scan of the knee in 30° flexion was the most sensitive position to detect fluid in knee joints. Sagittal diameter of fluid in all 3 recesses increased with the knee in the 30° flexed position as compared to the extended position.

Entscheidungshilfen für eine nachhaltige räumliche Entwicklung der Bioenergiebereitstellung – Methoden und ihre instrumentelle Anwendung

In Anbetracht einer Bioenergiebereitstellung, die voraussichtlich weiter an Bedeutung gewinnt und weiter Raum greift, stehen viele Regionen vor der Frage, mit welchen Entwicklungen sie konkret zu rechnen haben und wie sie diesen Entwicklungen begegnen können. Um Antworten auf diese Fragen zu finden und in der Konsequenz regionale Steuerungsmöglichkeiten für eine nachhaltige räumliche Entwicklung der Bioenergiebereitstellung zu ermitteln, wurde am Beispiel der Planungsregion Westsachsen eine Methode entwickelt, die auch als Handreichung für andere Regionen dienen kann. Sie erlaubt, die regionalen räumlichen Potenziale für die Bioenergiebereitstellung nach Fruchtarten und Anlagentypen differenziert zu ermitteln, mögliche Entwicklungen in qualitativen Szenarien zu vergegenwärtigen und voraussichtliche Umweltauswirkungen und Flächenkonkurrenzen zu beurteilen. Instrumentell kann die Methode in einem Biomasseentwicklungskonzept umgesetzt werden, das auch als Beitrag zu möglichen künftigen Regionalen Energiekonzepten dienen kann. Konzipiert ist es weniger als finales Konzept, vielmehr als flexibles Instrument in Form eines planerischen Rahmens. Dies hat den Vorteil, anpassungsfähig zu sein und dem regionalen Diskurs Raum zu eröffnen. Damit hat die Methode das Potenzial, einen Beitrag zur regionalen Zielfindung zu leisten.

Validity of ultrasonography and measures of adult shoulder function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis using magnetic resonance imaging as a gold standard

OBJECTIVE

To assess the intra- and interobserver reproducibility of musculoskeletal ultrasonography (US) in detecting inflammatory shoulder changes in patients with rheumatoid arthritis, and to determine the agreement between US and the Shoulder Pain and Disability Index (SPADI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, using magnetic resonance imaging (MRI) as a gold standard.

METHODS

Eleven rheumatologists investigated 10 patients in 2 rounds independently and blindly of each other by US. US results were compared with shoulder function tests and MRI.

RESULTS

The positive and negative predictive values (NPVs) for axillary recess synovitis (ARS) were 0.88 and 0.43, respectively, for posterior recess synovitis (PRS) were 0.36 and 0.97, respectively, for subacromial/subdeltoid bursitis (SASB) were 0.85 and 0.28, respectively, and the NPV for biceps tenosynovitis (BT) was 1.00. The intraobserver kappa was 0.62 for ARS, 0.59 for PRS, 0.51 for BT, and 0.70 for SASB. The intraobserver kappa for power Doppler US (PDUS) signal was 0.91 for PRS, 0.77 for ARS, 0.94 for SASB, and 0.53 for BT. The interobserver maximum kappa was 0.46 for BT, 0.95 for ARS, 0.52 for PRS, and 0.61 for SASB. The interobserver reliability of PDUS was 1.0 for PRS, 0.1 for ARS, 0.5 for BT, and 1.0 for SASB. P values for the SPADI and DASH versus cuff tear on US were 0.02 and 0.01, respectively; all other relationships were not significant.

CONCLUSION

Overall agreements between gray-scale US and MRI regarding synovitis of the shoulder varied considerably, but excellent results were seen for PDUS. Measures of shoulder function have a poor relationship with US and MRI. Improved standardization of US scanning technique could further reliability of shoulder US.

Effectiveness of chondroitin sulphate in patients with concomitant knee osteoarthritis and psoriasis: a randomized, double-blind, placebo-controlled study

OBJECTIVE

The aim of the trial was to assess the efficacy of chondroitin sulphate (CS) on symptomatic knee osteoarthritis (OA) associated to psoriasis.

METHODS

In this randomized, double-blind, placebo (PBO)-controlled clinical trial 129 patients with symptomatic knee OA and concomitant psoriasis were randomized into two groups receiving 800 mg daily of CS or PBO for 3 months. The primary efficacy outcome for knee OA was the Huskisson's visual analogue scale (VAS) and for psoriasis was the Psoriasis Area and Severity Index (PASI). Additionally, other secondary efficacy criteria for both conditions were assessed.

RESULTS

After 3 months of treatment, CS was more effective than PBO, relieving pain VAS (CS -26.9+/-24.8 vs PBO -14.23+/-20.8mm, P<0.01), decreasing the Lequesne index (CS -4.8+/-3.4 vs PBO -3.3+/-3.5, P<0.05) and reducing the number of patients using acetaminophen as rescue medication (CS 43% vs PBO 64%, P<0.05). Regarding PASI, Overall Lesion Severity Scale and Physician's Global Assessment of Change no statistically significant changes were detected in front of PBO. However, CS improved plantar psoriasis compared to PBO (CS 87% vs PBO 27%, P<0.05). Quality of life improved significantly in CS-treated patients according to the Short Form-36 health survey and the Dermatology Life Quality Index (DLQI). CS tolerability was excellent. Adverse events were infrequent and evenly distributed among groups. The incidence of psoriatic flares did not increase after treatments.

CONCLUSIONS

This study confirms the efficacy and safety of CS as a symptomatic slow-acting drug in patients with knee OA and shows that CS improves plantar psoriasis. The use of CS could represent a special benefit in patients with both pathologies since non-steroidal anti-inflammatory drugs have been reported to induce or exacerbate psoriasis.

Three-dimensional volumetric ultrasonography. Does it improve reliabililty of musculoskeletal ultrasound?

OBJECTIVE

To compare the interobserver reliability of three-dimensional (3D) volumetric ultrasonography (US) and 2D real-time US in detecting inflammatory and destructive changes in rheumatoid arthritis (RA) wrist and hand.

METHODS

Two RA patients were selected by a rheumatologist who performed independently a grey-scale and power Doppler (PD) volumetric acquisition at three anatomic sites in their more symptomatic wrist/hand using two identical scanners equipped with 3D volumetric probe. Twelve rheumatologists expert in MSUS were randomly assigned to a US scanner and a patient. In the first part of the study, each group of experts blindly, independently, and consecutively performed a 2D real-time grey-scale and PD US investigation of inflammatory changes and/or bone erosions at the three anatomic sites. In the second part of the study, each group of investigators blindly evaluated the same pathologic changes in the 6 volumes from the patient not scanned by them.

RESULTS

The kappa values were higher for 3D volumetric US than for 2D US in the detection of synovitis/tenosyno-vitis (0.41 vs. 0.37) and PD signal (0.82 vs 0.45) and in the PD signal grading (0.81 vs. 0.55).

CONCLUSION

3D volumetric US may improve the interobserver reliability in RA multicentre studies.

[Hand hygiene and campaigns]

BACKGROUND

Hand disinfection is a well-known and appropriate practise for infection prevention. Hence, it is logical to encourage its compliance and to provide its sustainability in the daily routine of a hospital. Several campaigns address an improvement of this important prevention measure.

METHODS

In the Hannover Medical School the health staffs on the intensive care units and bone marrow transplantation wards were examined for this topic by a standardised questionnaire. The aim was to detect deficiencies and the level of knowledge.

RESULTS

The forms were handed out to 838 health-care workers on 12 wards. 346 (41.2 %) were analysed. Inadequate hand disinfection due to a lack of time was the most common answer (43.1 %), followed by "there is no reason" (37.3 %). The alcoholic hand rub should be better available (50.3 %) and a continuing education programme should be provided (42.8 %) for improving hand hygiene practise.

CONCLUSION

The survey revealed the known risk factors for non-compliance. At this point, the national hand campaign "Aktion Saubere Hände" supports training courses by providing instruction materials for all participants. These materials are used for training health-care workers individually.

Ultrasound in the study and monitoring of osteoarthritis

This review addresses the use of ultrasound (US) as an imaging technique for the evaluation and monitoring of the osteoarthritic joint. US complements both the clinical examination and radiological imaging by allowing the rheumatologist to recognize not only the bony profile but also to visualize the soft tissues. Systematic US scanning following established guidelines can demonstrate even minimal abnormalities of articular cartilage, bony cortex and synovial tissue. US is also extremely sensitive in the detection of soft tissue changes in the involved joints including the proliferation of the synovium and changes in the amount of fluid present within the joint. Monitoring the amount of fluid in the hip and knee joint with osteoarthritis may be a potentially useful finding in the selection of patients for clinical investigation and for assessing their response to therapeutic interventions.

Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis

Objective:

To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI.

Methods:

A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated.

Results:

Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver κ was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, −0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver κ for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively.

Conclusions:

US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.

Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses

OBJECTIVE

To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses.

METHODS

We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels.

RESULTS

The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses.

CONCLUSION

We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

Gender and socio-economic variations in employment among patients with a diagnosed musculoskeletal disorder: a longitudinal record linkage study in Sweden

OBJECTIVE

To establish whether the employment consequences of musculoskeletal disorder vary by gender and socio-economic group in Sweden.

METHODS

Two linked registers, containing diagnostic and socio-economic data for the 1.8 million residents of Stockholm County, were used to investigate the subsequent employment consequences over 5 yr of having a musculoskeletal disorder requiring hospital admission in 1996. Age-standardized employment rates of all patients with musculoskeletal disorder (n = 2185) were compared with patients employed prior to hospital admission (n = 1286) and with the general population of Stockholm. Odds of leaving employment between 1996-2001 were calculated for men, women and patients from different socio-economic groups.

RESULTS

Employment rates increased and social differentials narrowed in the general population, while employment declined and social differentials widened among patients with musculoskeletal disorders. These trends were masked when analyses were restricted to individuals employed at baseline. Following hospital admission, the odds of leaving employment increased annually for patients; by 2001, their adjusted odds were over three times greater [odds ratio (OR) = 3.36, 95% confidence interval (CI) 2.89-3.91] than for the general population. Women with musculoskeletal disorders were significantly more likely to leave employment during follow-up than men (OR = 1.95, 95% CI 1.49-2.56). Semi- and unskilled manual workers with musculoskeletal disorders were over three times as likely to leave employment than their professional counterparts (OR = 3.40, 95% CI 2.41-4.81).

CONCLUSIONS

People with musculoskeletal disorders, particularly women and semi- and unskilled manual workers, are vulnerable to leaving employment. Health and social policies must do more to protect the employment of people with musculoskeletal disorders.

Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course

OBJECTIVE

To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography.

METHODS

The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results.

RESULTS

Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae.

CONCLUSIONS

Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.