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Chasov V, Ganeeva I, Zmievskaya E, Davletshin D, Gilyazova E, Valiullina A, Bulatov E. Cell-Based Therapy and Genome Editing as Emerging Therapeutic Approaches to Treat Rheumatoid Arthritis. Cells 2024; 13:1282. [PMID: 39120313 PMCID: PMC11312096 DOI: 10.3390/cells13151282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/19/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024] Open
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation of the joints. Although much remains unknown about the pathogenesis of RA, there is evidence that impaired immune tolerance and the development of RA are related. And it is precisely the restoration of immune tolerance at the site of the inflammation that is the ultimate goal of the treatment of RA. Over the past few decades, significant progress has been made in the treatment of RA, with higher rates of disease remission and improved long-term outcomes. Unfortunately, despite these successes, the proportion of patients with persistent, difficult-to-treat disease remains high, and the task of improving our understanding of the basic mechanisms of disease development and developing new ways to treat RA remains relevant. This review focuses on describing new treatments for RA, including cell therapies and gene editing technologies that have shown potential in preclinical and early clinical trials. In addition, we discuss the opportunities and limitations associated with the use of these new approaches in the treatment of RA.
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Affiliation(s)
- Vitaly Chasov
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
| | - Irina Ganeeva
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
| | - Ekaterina Zmievskaya
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
| | - Damir Davletshin
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
| | - Elvina Gilyazova
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
| | - Aygul Valiullina
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
| | - Emil Bulatov
- Laboratory of Biomedical Technologies, Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya Street, Kazan 420008, Russia
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow 117997, Russia
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow 119048, Russia
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Malham M, Jansson S, Ingels H, Jørgensen MH, Rod NH, Wewer V, Fox MP. Paediatric-onset immune-mediated inflammatory disease is associated with an increased mortality risk-A nationwide study. Aliment Pharmacol Ther 2024; 59:1551-1558. [PMID: 38597407 DOI: 10.1111/apt.17994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/16/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Paediatric-onset immune-mediated inflammatory diseases (pIMID) show more aggressive phenotypes than when diagnosed in adults. However, data on mortality are often extrapolated from adult studies. AIM To estimate the effect of pIMID on mortality. METHODS In a population-based cohort study using the nationwide Danish healthcare registers, we included all patients diagnosed with pIMID in Denmark from 1980 to 2018. PIMID were defined as ICD codes indicative of autoimmune hepatitis, primary sclerosing cholangitis, Crohn's disease, ulcerative colitis, juvenile idiopathic arthritis, lupus erythematosus, or vasculitis registered before age 18 years. All-cause mortality was the primary outcome; cause-specific mortality was the secondary outcome. We used Cox survival analysis to estimate hazard ratios (HR), and Aalen survival analysis to estimate rate differences. RESULTS We included 11,581 individuals diagnosed with pIMID and 99,665 reference individuals, accounting for 1,371,994 person-years of follow-up. Median and interquartile (IQR) age at diagnosis was 12.6 (7.9-15.9) years. During follow-up, 152 patients with pIMID and 316 reference individuals died; adjusted HR (aHR) was 3.8 (95% confidence interval [CI] 3.1-4.7). This corresponded to 6.9 (95% CI: 5.3-8.5) additional deaths per 10,000 person-years. The strongest associations were found for gastrointestinal diseases (aHR 22.8; 95% CI 9.6-64.1), gastrointestinal cancers (aHR 19.2; 95% CI 5.0-74.2) and lymphoproliferative disorders (aHR 6.8; 95% CI 2.8-16.8). CONCLUSION Patients diagnosed with pIMID have a fourfold higher risk of mortality when followed into early adulthood compared with reference individuals. This underlines the severe disease course of pIMID and highlights the need for multidisciplinary care.
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Affiliation(s)
- Mikkel Malham
- Department of Paediatric and Adolescence Medicine, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents, and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sabine Jansson
- Department of Paediatric and Adolescence Medicine, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents, and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Helene Ingels
- Department of Paediatrics and Adolescence Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Marianne Hørby Jørgensen
- Department of Paediatrics and Adolescence Medicine, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Naja Hulvej Rod
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Wewer
- Department of Paediatric and Adolescence Medicine, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents, and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Yu T, Yang C. Multifocal leukoencephalopathy in a patient medicated with etanercept and methotrexate for rheumatoid arthritis. Z Rheumatol 2024; 83:297-302. [PMID: 37755473 DOI: 10.1007/s00393-023-01430-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023]
Abstract
Methotrexate (MTX) and etanercept are commonly used in the treatment of rheumatoid arthritis (RA). Several important adverse events, including central nervous system lesions, have been reported during RA treatment. Among them, MTX-induced leukoencephalopathy is a recognized complication that is often observed following intrathecal or intravenous MTX administration. Herein, we report a case of a RA patient who was diagnosed with multifocal leukoencephalopathy during etanercept and MTX therapy. A 77-year-old Chinese woman with a 3-year history of RA had been taking subcutaneous etanercept and low-dose oral MTX since February 2021. Five months after the initial administration, she developed cognitive impairment and experienced a dropped attack. She was then admitted to our hospital in June 2021. T2-weighted magnetic resonance imaging (MRI) images revealed disseminated lesions in the white matter of the brain. Based on these MRI findings and extensive clinical investigation that excluded other possible causes of white matter lesions, she was suspected of having a demyelinating disorder. There was no evidence suggesting other neurological disorders. High-dose corticosteroid was administered, which resulted in improved cognitive impairment. This case report illustrates an important example of multifocal leukoencephalopathy induced by the combined use of etanercept and MTX, which resolved with high-dose corticosteroid. With the recent emphasis on various biologic agents for treatment of RA, our case highlights the importance of identifying leukoencephalopathy that may be induced by various biologics.
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Affiliation(s)
- Tieer Yu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, 247 Renmin Road, Ningbo, China
| | - Chunying Yang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, 247 Renmin Road, Ningbo, China.
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Trovato E, Dragotto M, Capalbo E, Cartocci A, Rubegni P, Calabrese L. Risk of Skin Cancer in Patients with Psoriasis: Single-Center Retrospective Study Comparing Anti-TNFα and Phototherapy. J Clin Med 2024; 13:2452. [PMID: 38730981 PMCID: PMC11084754 DOI: 10.3390/jcm13092452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/06/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Background: The risk of developing non-melanoma skin cancers (NMSCs) in patients with psoriasis is highly debated, and, to date, there is no unambiguous consensus opinion. Psoriasis is known to be related to an increased likelihood of other comorbidities such as psoriatic arthritis, obesity, metabolic syndrome, depression, and cardiovascular disease. Regarding cancer risk, previous studies have reported a greater tendency for the development of cutaneous T-lymphomas and colon, breast, kidney, and lung cancers. Furthermore, data from network meta-analyses have shown that patients with psoriasis have a higher risk of developing squamous cell carcinomas (SCCs) and/or basal cell carcinomas (BCCs). Multiple factors may contribute to the development of NMSCs in psoriatic patients, ranging from immunosuppression induced by biologic agents to previous phototherapy. However, the extent to which each factor may impact this risk has not been entirely assessed. The aim of this study was to evaluate the risk of developing NMSCs in patients with psoriasis observed for at least 5 years, by directly comparing patients only treated with phototherapy and patients treated with anti-tumor necrosis factor α (TNFα) agents, naive to other systemic treatments or phototherapy. Methods: We conducted a single-center retrospective study at Siena University Hospital, Italy, on 200 adult patients with psoriasis divided into two groups: (i) group 1, including 100 patients treated with narrow-band UVB phototherapy (nb-UVB), and (ii) group 2, including 100 patients treated with anti-TNFα. The patients included in group 2 had to be naive to cDMARDs and biologics and treated with anti-TNFα continuously for 5 years without loss of efficacy. All patients were observed for 5 years and underwent annual dermatologic examinations to assess for the occurrence of BCC or SCC. Results: A total of 34 out of 100 patients treated with phototherapy had one BCC or one SCC and 10 out of 34 developed two skin cancers. In particular, five had both types (one BCC and one SCC), and five had two BCCs. Conclusions: The results of our study highlight how the risk of developing NMSCs is greater in patients undergoing phototherapy compared to those treated with anti-TNFα. It also draws attention to the consideration that patients with scalp psoriasis might need closer follow-up as they could be more at risk of developing NMSCs.
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Affiliation(s)
- Emanuele Trovato
- Dermatology Unit, Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (E.T.); (M.D.); (P.R.)
| | - Martina Dragotto
- Dermatology Unit, Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (E.T.); (M.D.); (P.R.)
| | - Eugenio Capalbo
- Dermatology Unit, Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (E.T.); (M.D.); (P.R.)
| | - Alessandra Cartocci
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy
| | - Pietro Rubegni
- Dermatology Unit, Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (E.T.); (M.D.); (P.R.)
| | - Laura Calabrese
- Dermatology Unit, Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (E.T.); (M.D.); (P.R.)
- Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Zhao W, Fang P, Lai C, Xu X, Wang Y, Liu H, Jiang H, Liu X, Liu J. Proteome-wide Mendelian randomization identifies therapeutic targets for ankylosing spondylitis. Front Immunol 2024; 15:1366736. [PMID: 38566994 PMCID: PMC10985162 DOI: 10.3389/fimmu.2024.1366736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Background Ankylosing Spondylitis (AS) is a chronic inflammatory disorder which can lead to considerable pain and disability. Mendelian randomization (MR) has been extensively applied for repurposing licensed drugs and uncovering new therapeutic targets. Our objective is to pinpoint innovative therapeutic protein targets for AS and assess the potential adverse effects of druggable proteins. Methods We conducted a comprehensive proteome-wide MR study to assess the causal relationships between plasma proteins and the risk of AS. The plasma proteins were sourced from the UK Biobank Pharma Proteomics Project (UKB-PPP) database, encompassing GWAS data for 2,940 plasma proteins. Additionally, GWAS data for AS were extracted from the R9 version of the Finnish database, including 2,860 patients and 270,964 controls. The colocalization analysis was executed to identify shared causal variants between plasma proteins and AS. Finally, we examined the potential adverse effects of druggable proteins for AS therapy by conducting a phenome-wide association study (PheWAS) utilizing the extensive Finnish database in version R9, encompassing 2,272 phenotypes categorized into 46 groups. Results The findings revealed a positive genetic association between the predicted plasma levels of six proteins and an elevated risk of AS, while two proteins exhibited an inverse association with AS risk (P fdr < 0.05). Among these eight plasma proteins, colocalization analysis identified AIF1, TNF, FKBPL, AGER, ALDH5A1, and ACOT13 as shared variation with AS(PPH3+PPH4>0.8), suggesting that they represent potential direct targets for AS intervention. Further phenotype-wide association studies have shown some potential side effects of these six targets (P fdr < 0.05). Conclusion Our investigation examined the causal connections between six plasma proteins and AS, providing a comprehensive understanding of potential therapeutic targets.
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Affiliation(s)
- Wenlong Zhao
- Department of Orthopedics, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China
| | - Peng Fang
- Department of Orthopedics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chengteng Lai
- Department of Orthopedics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaoyu Xu
- Department of Biology, Wake Forest University, North Carolina, NC, United States
| | - Yang Wang
- Department of Orthopedics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Hao Liu
- Department of Orthopedics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Hui Jiang
- Department of Orthopedics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaozhou Liu
- Department of Orthopedics, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jun Liu
- Department of Orthopedics, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Hou XJ, Chang R, Wang YH, Kang TL, Wei JCC. Hydroxychloroquine had neutral effect on long-term risk of malignancy in rheumatoid arthritis patients: A population-based retrospective cohort study. Int J Rheum Dis 2024; 27:e15102. [PMID: 38450839 DOI: 10.1111/1756-185x.15102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/22/2024] [Accepted: 02/17/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND The cancer risk in rheumatoid arthritis (RA) patients has been discussed. Hydroxychloroquine (HCQ) may exert protective effects against malignancy. The study investigated the association between HCQ use and the risk of subsequent malignancy in RA patients. METHODS Catastrophic illness certificated RA patients were extracted from the National Health Insurance Research Database. The index date was set 180 days after the RA diagnosis date to avoid immortal time bias. Two groups were matched in a 1-to-1 ratio by propensity score regarding age, gender, index date, relevant comorbidities, and comedication. HCQ users prior to the diagnosis of RA were exempted to ensure compliance with the new-user design. Cancers diagnosed before or less than 180 days after the index date were excluded to mitigate protopathic bias. The study adopted the Kaplan-Meier curve and Cox proportional hazards model to examine the association between HCQ use and cancer risk. The assumption of proportional hazard was also tested. RESULTS Based on strict criteria, we included 492 eligible RA patients and divided them into study and control groups (N = 246 in each group). HCQ users exhibited a neutral risk of cancer relative to the controls (adjusted hazard ratio, 0.99; 95% CI, 0.44-2.21, p > .05). The assumption of proportional hazard was not violated. CONCLUSION This study does not observe the effect of using HCQ as a primary regimen to prevent cancer in RA patients. We are assured that HCQ is not associated with an increased risk of subsequent malignancy in RA patients. Further mechanistic research is needed.
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Affiliation(s)
- Xiu-Juan Hou
- Department of Rheumatism, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tian-Lun Kang
- Department of Rheumatism, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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Liu F, Ye J, Wang S, Li Y, Yang Y, Xiao J, Jiang A, Lu X, Zhu Y. Identification and Verification of Novel Biomarkers Involving Rheumatoid Arthritis with Multimachine Learning Algorithms: An In Silicon and In Vivo Study. Mediators Inflamm 2024; 2024:3188216. [PMID: 38385005 PMCID: PMC10881253 DOI: 10.1155/2024/3188216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/02/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
Background Rheumatoid arthritis (RA) remains one of the most prevalent chronic joint diseases. However, due to the heterogeneity among RA patients, there are still no robust diagnostic and therapeutic biomarkers for the diagnosis and treatment of RA. Methods We retrieved RA-related and pan-cancer information datasets from the Gene Expression Omnibus and The Cancer Genome Atlas databases, respectively. Six gene expression profiles and corresponding clinical information of GSE12021, GSE29746, GSE55235, GSE55457, GSE77298, and GSE89408 were adopted to perform differential expression gene analysis, enrichment, and immune component difference analyses of RA. Four machine learning algorithms, including LASSO, RF, XGBoost, and SVM, were used to identify RA-related biomarkers. Unsupervised cluster analysis was also used to decipher the heterogeneity of RA. A four-signature-based nomogram was constructed and verified to specifically diagnose RA and osteoarthritis (OA) from normal tissues. Consequently, RA-HFLS cell was utilized to investigate the biological role of CRTAM in RA. In addition, comparisons of diagnostic efficacy and biological roles among CRTAM and other classic biomarkers of RA were also performed. Results Immune and stromal components were highly enriched in RA. Chemokine- and Th cell-related signatures were significantly activated in RA tissues. Four promising and novel biomarkers, including CRTAM, PTTG1IP, ITGB2, and MMP13, were identified and verified, which could be treated as novel treatment and diagnostic targets for RA. Nomograms based on the four signatures might aid in distinguishing and diagnosing RA, which reached a satisfactory performance in both training (AUC = 0.894) and testing (AUC = 0.843) cohorts. Two distinct subtypes of RA patients were identified, which further verified that these four signatures might be involved in the immune infiltration process. Furthermore, knockdown of CRTAM could significantly suppress the proliferation and invasion ability of RA cell line and thus could be treated as a novel therapeutic target. CRTAM owned a great diagnostic performance for RA than previous biomarkers including MMP3, S100A8, S100A9, IL6, COMP, LAG3, and ENTPD1. Mechanically, CRTAM could also be involved in the progression through immune dysfunction, fatty acid metabolism, and genomic instability across several cancer subtypes. Conclusion CRTAM, PTTG1IP, ITGB2, and MMP13 were highly expressed in RA tissues and might function as pivotal diagnostic and treatment targets by deteriorating the immune dysfunction state. In addition, CRTAM might fuel cancer progression through immune signals, especially among RA patients.
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Affiliation(s)
- Fucun Liu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Juelan Ye
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
- Spinal Tumor Center, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Shouli Wang
- Orthopedics Research Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang, China
| | - Yang Li
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yuhang Yang
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Jianru Xiao
- Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
- Spinal Tumor Center, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Aimin Jiang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xuhua Lu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yunli Zhu
- Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
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Song M, Engels EA, Clarke MA, Kreimer AR, Shiels MS. Autoimmune disease and the risk of anal cancer in the US population aged 66 years and over. J Natl Cancer Inst 2024; 116:309-315. [PMID: 37701981 PMCID: PMC10852610 DOI: 10.1093/jnci/djad187] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/10/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND In the United States, anal squamous cell carcinoma rates have increased rapidly, particularly among women 50 or older than 66 years of age. As immunosuppression is associated with increased risk, autoimmune conditions may be associated with greater risk of anal squamous cell carcinoma. METHODS We conducted a population-based, case-control study using Surveillance, Epidemiology, and End Results-Medicare data (2000-2017). Anal squamous cell carcinoma cases (n = 4505) were matched to 200 000 cancer-free controls. Using multivariable logistic regression, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) for associations between 47 autoimmune conditions diagnosed before selection, identified using Medicare claims, and anal squamous cell carcinoma. The Bonferroni threshold was used to correct for multiple comparisons. Population attributable fractions were calculated for conditions nominally associated with anal squamous cell carcinoma. RESULTS In total, 18% of anal squamous cell carcinoma cases and 15% of cancer-free controls had a diagnosed autoimmune condition. Any autoimmune condition was associated with an increased risk of anal squamous cell carcinoma (OR = 1.11, 95% CI = 1.02 to 1.21; population attributable fraction = 1.8%). Anal squamous cell carcinoma was associated with systemic lupus erythematosus (OR = 1.79, 95% CI = 1.32 to 2.42; population attributable fraction = 0.4%) and nominally associated (P < .05) with sarcoidosis (OR = 2.09, 95% CI = 1.30 to 3.37; population-attributable fraction = 0.2%) and psoriasis (OR = 1.28, 95% CI = 1.06 to 1.56; population attributable fraction = 0.5%). Stratified by sex, only women showed statistically significant associations for systemic lupus erythematosus (OR = 1.97, 95% CI = 1.46 to 2.68). Statistically significant interaction was observed by sex for psoriasis (men vs women: OR = 1.68 [95% CI = 1.03 to 4.28] vs OR = 1.12 [95% CI = 0.88 to 1.43]) and polymyalgia rheumatica (OR = 0.33 [95% CI = 0.12 to 0.89] vs OR = 0.99 [95% CI = 0.75 to 1.30]). CONCLUSION Systemic lupus erythematosus, sarcoidosis, and psoriasis were associated with a moderately increased risk of anal squamous cell carcinoma. Given these conditions' rarity and moderate associations with anal squamous cell carcinoma, autoimmune diseases cannot explain the rising trend in this disease.
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Affiliation(s)
- Minkyo Song
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Gensmyr-Singer H, Karling P. What Happens to Patients with Inflammatory Bowel Disease Who Are Intolerant to Thiopurines? Inflamm Intest Dis 2024; 9:135-146. [PMID: 39015258 PMCID: PMC11249451 DOI: 10.1159/000539287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/04/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction The clinical consequences for patients with inflammatory bowel disease (IBD) who stop treatment owing to side effects have not been fully investigated. Methods This retrospective observational study aimed to compare patients who discontinued thiopurine treatment due to side effects with those who tolerated thiopurine treatment in the use of other IBD drugs, surgery, and fecal calprotectin values in the first 5 years after the start of thiopurine treatment. Results The proportion of patients with IBD who initiated thiopurine treatment at our clinic was 44% (32% ulcerative colitis and 64% Crohn's disease) and 31% (n = 94) of those patients had to stop thiopurine treatment within 5 years due to side effects. Patients who discontinued thiopurine treatment due to intolerance were significantly older (median age 33 vs. 27 years, p = 0.003), significantly more often used prednisolone (89 vs. 76%, p = 0.009), and used to a lesser extent TNF inhibitors at the start of thiopurine treatment (3% vs. 9%, p = 0.062). Budesonide treatment and non-TNF inhibitor second-line therapy were significantly more commonly used in patients who discontinued thiopurine treatment owing to side effects, but there were no statistically significant differences in the use of other treatments. The proportion of patients with a median FC >200 μg/g was significantly higher during follow-up in patients with UC who discontinued thiopurine treatment owing to side effects. Conclusions Patients who discontinued thiopurines owing to side effects were prescribed more budesonide and non-TNF inhibitor second-line therapy, but there were no differences in the use of TNF inhibitors, prednisolone, or surgery.
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Affiliation(s)
| | - Pontus Karling
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Adrianzen-Herrera D, Sparks AD, Singh R, Alejos-Castillo D, Batra A, Glushakow-Smith S, Pradhan K, Shastri A, Zakai NA. Impact of preexisting autoimmune disease on myelodysplastic syndromes outcomes: a population analysis. Blood Adv 2023; 7:6913-6922. [PMID: 37729616 PMCID: PMC10685168 DOI: 10.1182/bloodadvances.2023011050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/16/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023] Open
Abstract
Preexisting autoimmune disease affects between 10% and 30% of patients with myelodysplastic syndromes (MDS). Studies comparing outcomes in patients with MDS with and without autoimmune disease show discordant results. Using the Surveillance, Epidemiology, and End Results Medicare database, we conducted a population analysis to define the impact of autoimmunity on MDS outcomes. Cases were ascertained between 2007 and 2017 and claim algorithms used to identify autoimmune disease, demographic characteristics, comorbidity scores, MDS histology, transfusion burden, treatment with hypomethylating agents, and hematopoietic stem cell transplantation. Cox regression models estimated the impact on survival, and competing-risk regression models defined the effect on leukemic transformation. We analyzed 15 277 patients with MDS, including 2442 (16%) with preexisting autoimmune disease. The epidemiologic profile was distinctive in cases with preexisting autoimmunity, who were younger, were predominantly female, and had higher transfusion burden without difference in MDS histologic distribution. Autoimmune disease was associated with 11% decreased risk of death (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.85-0.94; P < .001). The effect on risk of leukemic transformation differed based on MDS histology. In low-risk MDS histologies, autoimmunity was associated with a 1.9-fold increased risk of leukemia (HR, 1.87; 95% CI, 1.17-2.99; P = .008), whereas no significant effect was seen in other groups. These results suggest that autoimmune disease affects survival in MDS and is associated with decreased mortality. The survival effect was evident in low-risk histologies despite higher risk of progression to leukemia. This could represent inflammation-driven hematopoiesis, simultaneously favoring less aggressive phenotypes and clonal expansion, which warrants further investigation.
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Affiliation(s)
- Diego Adrianzen-Herrera
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Andrew D. Sparks
- Biomedical Statistics Research Core, University of Vermont, Burlington, VT
| | - Rohit Singh
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - David Alejos-Castillo
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Akshee Batra
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT
| | | | - Kith Pradhan
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Aditi Shastri
- Department of Oncology, Albert Einstein College of Medicine, Bronx, NY
| | - Neil A. Zakai
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
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11
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Neale RE, Lucas RM, Byrne SN, Hollestein L, Rhodes LE, Yazar S, Young AR, Berwick M, Ireland RA, Olsen CM. The effects of exposure to solar radiation on human health. Photochem Photobiol Sci 2023:10.1007/s43630-023-00375-8. [PMID: 36856971 PMCID: PMC9976694 DOI: 10.1007/s43630-023-00375-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
This assessment by the Environmental Effects Assessment Panel (EEAP) of the Montreal Protocol under the United Nations Environment Programme (UNEP) evaluates the effects of ultraviolet (UV) radiation on human health within the context of the Montreal Protocol and its Amendments. We assess work published since our last comprehensive assessment in 2018. Over the last four years gains have been made in knowledge of the links between sun exposure and health outcomes, mechanisms, and estimates of disease burden, including economic impacts. Of particular note, there is new information about the way in which exposure to UV radiation modulates the immune system, causing both harms and benefits for health. The burden of skin cancer remains high, with many lives lost to melanoma and many more people treated for keratinocyte cancer, but it has been estimated that the Montreal Protocol will prevent 11 million cases of melanoma and 432 million cases of keratinocyte cancer that would otherwise have occurred in the United States in people born between 1890 and 2100. While the incidence of skin cancer continues to rise, rates have stabilised in younger populations in some countries. Mortality has also plateaued, partly due to the use of systemic therapies for advanced disease. However, these therapies are very expensive, contributing to the extremely high economic burden of skin cancer, and emphasising the importance and comparative cost-effectiveness of prevention. Photodermatoses, inflammatory skin conditions induced by exposure to UV radiation, can have a marked detrimental impact on the quality of life of sufferers. More information is emerging about their potential link with commonly used drugs, particularly anti-hypertensives. The eyes are also harmed by over-exposure to UV radiation. The incidence of cataract and pterygium is continuing to rise, and there is now evidence of a link between intraocular melanoma and sun exposure. It has been estimated that the Montreal Protocol will prevent 63 million cases of cataract that would otherwise have occurred in the United States in people born between 1890 and 2100. Despite the clearly established harms, exposure to UV radiation also has benefits for human health. While the best recognised benefit is production of vitamin D, beneficial effects mediated by factors other than vitamin D are emerging. For both sun exposure and vitamin D, there is increasingly convincing evidence of a positive role in diseases related to immune function, including both autoimmune diseases and infection. With its influence on the intensity of UV radiation and global warming, the Montreal Protocol has, and will have, both direct and indirect effects on human health, potentially changing the balance of the risks and benefits of spending time outdoors.
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Affiliation(s)
- R. E. Neale
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD Australia ,School of Public Health, University of Queensland, Brisbane, QLD Australia
| | - R. M. Lucas
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT Australia
| | - S. N. Byrne
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - L. Hollestein
- Erasmus MC Cancer Institute, Rotterdam, The Netherlands ,Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - L. E. Rhodes
- Dermatology Research Centre, School of Biological Sciences, University of Manchester, Salford Royal Hospital, Northern Care Alliance NHS Trust, Manchester, UK
| | - S. Yazar
- Garvan Medical Research Institute, Sydney, NSW Australia
| | | | - M. Berwick
- University of New Mexico Comprehensive Cancer Center, Albuquerque, USA
| | - R. A. Ireland
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - C. M. Olsen
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, QLD Australia ,Frazer Institute, University of Queensland, Brisbane, QLD Australia
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12
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Yoshida S, Fujita M, Ishigame T, Kobayashi Y, Sumichika Y, Saito K, Matsumoto H, Temmoku J, Fujita Y, Matsuoka N, Asano T, Sato S, Watanabe H, Yoshida H, Marubashi S, Hashimoto Y, Ohira H, Migita K. Case report: Unusual development of hepatocellular carcinoma during immunosuppressive treatments against rheumatoid arthritis overlapping Sjögren's syndrome; cirrhotic steatohepatitis with liver inflammation and fibrosis lurks in autoimmune disorders. Front Immunol 2023; 14:1089492. [PMID: 36875090 PMCID: PMC9975153 DOI: 10.3389/fimmu.2023.1089492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/03/2023] [Indexed: 02/17/2023] Open
Abstract
The sequential progression from chronic liver disease to cirrhosis may be a risk factor for hepatocellular carcinoma (HCC) development. Although HCC originates from hepatitis B virus- or hepatitis C virus-associated liver cirrhosis, it has recently been reported in patients with non-alcoholic steatohepatitis (NASH) with advanced fibrosis. However, little is known about the pathophysiological mechanisms linking HCC to rheumatic disorders, including rheumatoid arthritis (RA). Herein, we describe the case of HCC with NASH complicated by RA and Sjögren's syndrome (SS). A fifty-two-year-old patient with RA and diabetes was referred to our hospital for further examination of a liver tumor. She received methotrexate (4 mg/week) for 3 years and adalimumab (40 mg/biweekly) for 2 years. On admission, laboratory data showed mild thrombocytopenia and hypoalbuminemia, with normal hepatitis virus markers or liver enzymes. Anti-nuclear antibodies were positive with high titers (x640), and anti-SS-A/Ro (187.0 U/ml; normal range [NR]: ≤6.9 U/mL) and anti-SS-B/La (320 U/ml; NR: ≤6.9 U/mL) antibodies were also high. Abdominal ultrasonography and computed tomography revealed liver cirrhosis and a tumor in the left lobe (S4) of the liver. She was diagnosed with HCC based on imaging findings, and elevated levels of protein induced by vitamin K absence- II (PIVKA-II) were detected. She underwent laparoscopic partial hepatectomy, and histopathological examination revealed steatohepatitis HCC with background liver cirrhosis. The patient was discharged on the 8th day post-operation without any complications. At the 30 months follow-up, no significant evidence of recurrence was observed. Our case suggests that clinical screening for HCC is needed in patients with RA who are at a high risk of NASH, as they may progress to HCC even without elevated liver enzymes.
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Affiliation(s)
- Shuhei Yoshida
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masashi Fujita
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Teruhide Ishigame
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yasuyuki Kobayashi
- Department of Diagnostic Pathology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuya Sumichika
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenji Saito
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroshi Yoshida
- Department of Internal Medicine, Kita-Fukushima Medical Center, Date, Japan
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuko Hashimoto
- Department of Diagnostic Pathology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
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13
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Tumor Necrosis Factor: What Is in a Name? Cancers (Basel) 2022; 14:cancers14215270. [DOI: 10.3390/cancers14215270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Tumor Necrosis Factor was one of the first cytokines described in the literature as a soluble mediator of cytotoxicity to tumors. Over the years, more extensive research that tried to employ Tumor Necrosis Factor in cancer treatments showed nevertheless that it mainly functioned as a proinflammatory cytokine. However, this did not stop the search for the holy grail of cancer research: A cytokine that could act as a one-stop treatment for solid tumors and lymphomas. This review will summarize the long experimental history of Tumor Necrosis Factor that caused the initial observations of a tumor necrotizing cytokine that could serve as a potential cancer treatment and discuss the current state of research into this side of the activities of Tumor Necrosis Factor.
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14
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Seror R, Lafourcade A, De Rycke Y, Pinto S, Castaneda J, Fautrel B, Mariette X, Tubach F. Risk of malignancy in rheumatoid arthritis patients initiating biologics: an historical propensity score matched cohort study within the French nationwide healthcare database. RMD Open 2022; 8:rmdopen-2021-002139. [PMID: 35738803 PMCID: PMC9226991 DOI: 10.1136/rmdopen-2021-002139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/22/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To compare the risk of malignancy between patients with rheumatoid arthritis (RA) initiating their first biological disease-modifying antirheumatic drug (bDMARD) and those continuing conventional synthetic DMARDs (csDMARDs). Methods Nine-year historical Propensity Score (PS) matched cohort study within the French national healthcare database (87% of the French population; ~57 million people), including adults RA without malignancy. Exposures started with the first use of any systemic treatment (csDMARDs and/or bDMARDs). Incident users of bDMARDs were matched on a dynamic PS to patients continuing csDMARDs. Their risk of malignancy was compared by Cox model. Results From 1 January 2007 to 31 December 2014, 83 706 patients with RA started their first systemic treatment (63 837 remained on csDMARDs and 19 869 initiated a bDMARD during follow-up). After dynamic PS matching, 19 727 bDMARD initiators were compared with 19 727 RA remaining on csDMARDs. They did not statistically differ in risk of overall malignancies (HR 0.99 (95% CI 0.86 to 1.14)), solid cancer (HR 0.95 (95% CI 0.82 to 1.11)), nor lymphoma (HR 1.35 (95% CI 0.72 to 2.53)). Results were similar when bDMARDs were given as monotherapy or in association with csDMARDs. Analyses restricted to patients starting TNF inhibitor as first bDMARD compared with matched RA remaining on csDMARDs, provided similar results (HR for overall malignancy 1.03 (95% CI 0.88 to 1.21)). Sensitivity analyses, varying carry-over periods (up to 5 years) to define risk periods, provided similar results. Conclusions In this historical cohort study within the French nationwide healthcare database, the risk of overall, solid or haematological malignancies did not significantly differ between patients with RA initiating bDMARD and those continuing csDMARDs.
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Affiliation(s)
- Raphaele Seror
- Service de Rhumatologie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Université Paris-Saclay, FHU CARE, Le Kremlin-Bicetre, France .,INSERM UMR 1184, Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicetre, France
| | - Alexandre Lafourcade
- Centre de Pharmacoépidémiologie (Cephepi), AP-HP. Sorbonne Université, Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Yann De Rycke
- Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), CIC-1901, Sorbonne Université, Faculté de médecine Sorbonne Université, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France.,Institut Pierre Louis d'epidemiologie, Sorbonne University, INSERM UMR-S 1136, Paris, France
| | - Sandrine Pinto
- Institut Pierre Louis d'epidemiologie, Sorbonne University, INSERM UMR-S 1136, Paris, France
| | - Johann Castaneda
- Centre de Pharmacoépidémiologie (Cephepi), AP-HP. Sorbonne Université, Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Bruno Fautrel
- Institut Pierre Louis d'epidemiologie, Sorbonne University, INSERM UMR-S 1136, Paris, France.,Service de Rhumatologie, Sorbonne Université, AP-HP.Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | - Xavier Mariette
- Service de Rhumatologie, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Université Paris-Saclay, FHU CARE, Le Kremlin-Bicetre, France.,INSERM UMR 1184, Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicetre, France
| | - Florence Tubach
- Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), CIC-1901, Sorbonne Université, Faculté de médecine Sorbonne Université, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France.,Institut Pierre Louis d'epidemiologie, Sorbonne University, INSERM UMR-S 1136, Paris, France.,delete this affiliaton, Paris, France
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