Stress as a risk factor in the pathogenesis of rheumatoid arthritis

Autoimmune Diseases Following Environmental Disasters: A Narrative Review of the Literature

Environmental disasters are extreme environmental processes such as earthquakes, volcanic eruptions, landslides, tsunamis, floods, cyclones, storms, wildfires and droughts that are the consequences of the climate crisis due to human intervention in the environment. Their effects on human health have alarmed the global scientific community. Among them, autoimmune diseases, a heterogeneous group of disorders, have increased dramatically in many parts of the world, likely as a result of changes in our exposure to environmental factors. However, only a limited number of studies have attempted to discover and analyze the complex association between environmental disasters and autoimmune diseases. This narrative review has therefore tried to fill this gap. First of all, the activation pathways of autoimmunity after environmental disasters have been analyzed. It has also been shown that wildfires, earthquakes, desert dust storms and volcanic eruptions may damage human health and induce autoimmune responses to inhaled PM2.5, mainly through oxidative stress pathways, increased pro-inflammatory cytokines and epithelial barrier damage. In addition, it has been shown that heat stress, in addition to increasing pro-inflammatory cytokines, may also disrupt the intestinal barrier, thereby increasing its permeability to toxins and pathogens or inducing epigenetic changes. In addition, toxic volcanic elements may accelerate the progressive destruction of myelin, which may potentially trigger multiple sclerosis. The complex and diverse mechanisms by which vector-borne, water-, food-, and rodent-borne diseases that often follow environmental diseases may also trigger autoimmune responses have also been described. In addition, the association between post-disaster stress and the onset or worsening of autoimmune disease has been demonstrated. Given all of the above, the rapid restoration of post-disaster health services to mitigate the flare-up of autoimmune conditions is critical.

The Dynamics of Resting-State EEG and Salivary Trace Elements in Patients with Obsessive-Compulsive Disorder

The study of salivary microelements and their neurophysiological and behavioral correlates in patients with obsessive-compulsive disorder (OCD) is a pressing issue in modern psychiatry, which, however, lacks adequate research at this time. In this study, we tested the dynamics of behavioral parameters, resting-state electroencephalogram (EEG), and salivary iron, copper, manganese, magnesium, and zinc in 30 healthy volunteers and 30 individuals with OCD before and after an emotional antisaccade task. The eye-movement data served as a measure of behavioral performance. Our research revealed consistently higher manganese concentrations in the OCD group compared to healthy volunteers associated with a higher EEG ratio of amplitude transformation and symptom severity. The dynamics of salivary microelements and resting-state EEG, possibly influenced by cognitive and emotional load during the anticsaccade task, differed between groups. In healthy volunteers, there was a decrease in salivary iron level with an increase in high-frequency power spectral density of EEG. The OCD group showed a decrease in salivary copper with an increased Hjorth mobility of EEG.

Personalized therapy in rheumatoid arthritis (PETRA): a protocol for a randomized controlled trial to test the effect of a psychological intervention in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects cartilage and bone. Psychological stress can both trigger disease exacerbation and result from disease activity. As standard pharmacological interventions alone have limited success in treating RA, a more comprehensive biopsychosocial approach to treatment has been recommended. In this prospective randomized controlled trial (RCT), a psychotherapeutically guided, group-based intervention program will be conducted with RA patients over a period of 9 months. This program combines a dynamic-interactional model with disorder-specific coping-oriented perspectives to improve patients' social, emotional, and problem-solving competencies as well as stress system functional status. The enrolment of 440 patients, randomly allocated to either an intervention (n = 220) or control group (n = 220), is planned. To evaluate the intervention effect, various indicators of RA disease activity, stress system activity, and psychological condition will be assessed through sets of standardized questionnaires and biochemical analyses of blood and saliva samples. Moreover, healthcare-related costs for each patient will be obtained using routine health insurance data. Outcome variables will be measured in all patients at regular intervals prior to intervention (baseline), during the 9-month intervention (five time points), and during a 9-month follow-up phase (three time points), allowing the comprehensive analysis of within- and between-subject effects, i.e. trajectories of the target variables in the intervention and control groups. In addition, to investigate the intervention effects on real-life stress system functioning in RA, 10 integrative single-case studies (n = 5 from the intervention group, n = 5 from the control group) will be conducted. In each study, once before and after the 9-month intervention, urine samples will be collected, and patients will fill out questionnaires for approximately 1 month at 12-h intervals. Moreover, weekly in-depth interviews will be conducted with patients to determine their previous week's emotionally positive and negative incidents. Using time series analysis, it is then possible to investigate whether and how stress system function in these RA patients has improved from the applied intervention. By using both an investigational macro- and microperspective, this project aims to evaluate a psychological intervention in the routine care of individuals with RA.Trial registration German Clinical Trials Register DRKS00028144. Registered on 1 March 2022.

Prolactin Inhibits or Stimulates the Inflammatory Response of Joint Tissues in a Cytokine-dependent Manner

The close association between rheumatoid arthritis (RA), sex, reproductive state, and stress has long linked prolactin (PRL) to disease progression. PRL has both proinflammatory and anti-inflammatory outcomes in RA, but responsible mechanisms are not understood. Here, we show that PRL modifies in an opposite manner the proinflammatory actions of IL-1β and TNF-α in mouse synovial fibroblasts in culture. Both IL-1β and TNF-α upregulated the metabolic activity and the expression of proinflammatory factors (Il1b, Inos, and Il6) via the activation of the nuclear factor-κB (NF-κB) signaling pathway. However, IL-1β increased and TNF-α decreased the levels of the long PRL receptor isoform in association with dual actions of PRL on synovial fibroblast inflammatory response. PRL reduced the proinflammatory effect and activation of NF-κB by IL-1β but increased TNF-α-induced inflammation and NF-κB signaling. The double-faceted role of PRL against the 2 cytokines manifested also in vivo. IL-1β or TNF-α with or without PRL were injected into the knee joints of healthy mice, and joint inflammation was monitored after 24 hours. IL-1β and TNF-α increased the joint expression of proinflammatory factors and the infiltration of immune cells. PRL prevented the actions of IL-1β but was either inactive or further increased the proinflammatory effect of TNF-α. We conclude that PRL exerts opposite actions on joint inflammation in males and females that depend on specific proinflammatory cytokines, the level of the PRL receptor, and the activation of NF-κB signaling. Dual actions of PRL may help balance joint inflammation in RA and provide insights for development of new treatments.

Effect of sound-induced repeated stress on the development of pain and inflammation in the temporomandibular joint of female and male rats

Temporomandibular disorder (TMD) is a common painful condition of the temporomandibular joint (TMJ) and associated structures. Stress is a significant risk factor for developing this painful condition that predominantly affects women. This study aimed to test the hypothesis that stress increases the risk of developing TMJ pain by facilitating inflammatory mechanisms in female and male rats. To test this hypothesis, we evaluated TMJ carrageenan-induced expression of pro-inflammatory cytokines and migration of inflammatory cells and TMJ formalin-induced nociception in female and male rats submitted to a repeated stress protocol induced by sound. We found that sound-induced repeated stress facilitates TMJ inflammation and contributes to TMJ nociception development equally in females and males. We conclude that stress is a risk factor for developing painful TMJ conditions in males and females, at least in part, by favoring the inflammatory process similarly in both sexes.

Associations between Cardiovascular Outcomes and Rheumatoid Arthritis: A Nationwide Population-Based Cohort Study

Despite a growing burden posed by cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients, large-scale studies on the association between the characteristics of RA patients and CVD risks and studies adjusted for various confounding factors are lacking. In this large-scale nationwide cohort study, we aimed to investigate the association between CVD risk and RA and factors that may increase CVD risk using a dataset provided by the Korean National Health Insurance Service (NHIS). We enrolled 136,469 patients with RA who participated in national health examinations within two years of RA diagnosis between 2010 and 2017 and non-RA controls matched by age and sex (n = 682,345). The outcome was the occurrence of myocardial infarction (MI) or stroke. MI was defined as one hospitalization or two outpatient visits with ICD-10-CM codes I21 or I22. Stroke was defined as one hospitalization with ICD-10-CM codes I63 or I64 and a claim for brain imaging (CT or MRI). The Cox proportional hazard model and Kaplan-Meier curve were used for analysis. The mean follow-up duration was 4.7 years, and the incidence rate of CVD was higher in the RA group than the control group (MI: 3.20 vs. 2.08; stroke: 2.84 vs. 2.33 per 1000 person-years). The risk of MI and stroke was about 50% and 20% higher, respectively, in RA patients. The association between RA and CVD was prominent in females after adjusting for confounding variables. The association between RA and risk of MI was significant in individuals without DM. Therefore, appropriate screening for CVD is important in all RA patients including females and younger patients.

Isoprenaline and salbutamol inhibit pyroptosis and promote mitochondrial biogenesis in arthritic chondrocytes by downregulating β-arrestin and GRK2

Rheumatoid arthritis and osteoarthritis overlap many molecular mechanisms of cartilage destruction. Wear and tear in cartilage is chondrocyte-mediated, where chondrocytes act both as effector and target cells. In current study, role of β2-AR was studied in chondrocytes both in vitro and in vivo. High grade inflammation in vitro and in vivo disease models led to decline in anti-inflammatory β2-AR signaling and use of β2-AR agonist attenuated arthritis symptoms. Detailed analysis in chondrocytes revealed that Isoprenaline (ISO) and Salbutamol (SBT) increased cell viability and relative Bcl-2 expression, meanwhile, decreased proteins levels of TNF-α, IL-6 and IL-8 in arthritic chondrocytes when compared with control, respectively. SBT preserved physiological concentration of antioxidant enzymes (CAT, POD, SOD and GSH) in cartilage homogenates and ISO inhibited IL-1β-mediated genotoxicity in arthritic chondrocytes. Moreover, β2-AR agonist increased mitochondrial biogenesis and proteoglycan biosynthesis by upregulating the gene expression of PGC1-α, NRF2 and COL2A1, Acan, respectively. ISO and SBT inhibited extracellular matrix (ECM) degradation by downregulating the gene expression of MMP1, MMP3, MMP9 and ADAMTS5 in vitro and in vivo study. In mechanism, β2-AR agonists decreased β-arrestin and GRK2 pathway, and as a result mice receiving SBT did not exhibit severe disease. Hence our data suggest β2-AR agonist administered at disease onset can inhibit receptor internalization by downregulating the expression of β-arrestin and GRK2 in chondrocytes.

Equitable Mindfulness: The practice of mindfulness for all

The benefits of mindfulness are well-documented; however, these benefits may not be evenly distributed across communities. Equitable Mindfulness aims to make these benefits accessible to a wider and more inclusive audience. The aim of this study was to investigate the applicability of Equitable Mindfulness and systemic barriers that prevent mindfulness programs from being equitably accessed across communities. Twenty-one participants were recruited for qualitative in-depth interviews during a 2-day mindfulness conference. The constant comparison method was used to iteratively identify and categorize themes that emerged within and across interviews. Five dominant themes emerged from the data as follows: inherent equitability, accessibility, inclusiveness, awareness and knowledge-sharing, and acknowledgement of multiple perspectives. Having an applicable and meaningful term to use when describing mindfulness as an inclusive and equitable practice can facilitate the exploration of a new area of research. There is a need for future initiatives aimed at making mindfulness trainings and programs more equitable and accessible to all, regardless of socioeconomic status, race/ethnicity, or abilities/disabilities.

Stress hormone signaling inhibits Th1 polarization in a CD4 T-cell-intrinsic manner via mTORC1 and the circadian gene PER1

Stress hormones are believed to skew the CD4 T‐cell differentiation towards a Th2 response via a T‐cell‐extrinsic mechanism. Using isolated primary human naïve and memory CD4 T cells, here we show that both adrenergic‐ and glucocorticoid‐mediated stress signalling pathways play a CD4 naïve T‐cell‐intrinsic role in regulating the Th1/Th2 differentiation balance. Both stress hormones reduced the Th1 programme and cytokine production by inhibiting mTORC1 signalling via two parallel mechanisms. Stress hormone signalling inhibited mTORC1 in naïve CD4 T cells (1) by affecting the PI3K/AKT pathway and (2) by regulating the expression of the circadian rhythm gene, period circadian regulator 1 (PER1). Both stress hormones induced the expression of PER1, which inhibited mTORC1 signalling, thus reducing Th1 differentiation. This previously unrecognized cell‐autonomous mechanism connects stress hormone signalling with CD4 T‐cell differentiation via mTORC1 and a specific circadian clock gene, namely PER1.

Dual Roles of Prolactin and Vasoinhibin in Inflammatory Arthritis

The term inflammatory arthritis defines a family of diseases, including rheumatoid arthritis (RA), caused by an overactive immune system, and influenced by host aspects including sex, reproductive state, and stress. Prolactin (PRL) is a sexually dimorphic, reproductive, stress-related hormone long-linked to RA under the general assumption that it aggravates the disease. However, this conclusion remains controversial since PRL has both negative and positive outcomes in RA that may depend on the hormone circulating levels, synthesis by joint tissues, and complex interactions at the inflammatory milieu. The inflamed joint is rich in matrix metalloproteases that cleave PRL to vasoinhibin, a PRL fragment with proinflammatory effects and the ability to inhibit the hyperpermeability and growth of blood vessels. This review addresses this field with the idea that explanatory mechanisms lie within the PRL/vasoinhibin axis, an integrative framework influencing not only the levels of systemic and local PRL, but also the proteolytic conversion of PRL to vasoinhibin, as vasoinhibin itself has dual actions on joint inflammation. In this review, we discuss recent findings from mouse models suggesting the upregulation of endogenous vasoinhibin by the pro-inflammatory environment and showing dichotomous actions and signaling mechanisms of PRL and vasoinhibin on joint inflammation that are cell-specific and context-dependent. We hypothesize that these opposing actions work together to balance the inflammatory response and provide new insights for understanding the pathophysiology of RA and the development of new treatments.

Adrenocortical dysfunction in rheumatoid arthritis: Α narrative review and future directions

BACKGROUND

Iatrogenic adrenal insufficiency (AI) secondary to long-term treatment with exogenous glucocorticoids (GC) is common in patients with systematic rheumatic diseases, including rheumatoid arthritis (RA). Moreover, a proportion of these patients is always in need of even small doses of glucocorticoids to maintain clinical remission, despite concomitant treatment with conventional and biologic disease-modifying drugs.

METHODS

We conducted a literature review up to December 2020 on (a) the incidence of AI in both long-term GC-treated and GC-treatment naïve RA patients; (b) the potential effects of increased levels of circulating proinflammatory cytokines, as well as of chronic stress, in adrenocortical function in RA; (c) the circadian cortisol rhythm in RA; and (d) established and evolving methods of assessment of adrenocortical function.

RESULTS

Up to 48% of RA patients develop glucocorticoid-induced AI; however, predictors are not established, while adrenocortical dysfunction may also occur in GC-treatment naïve RA patients. Experimental and clinical data have suggested that inadequate production of endogenous cortisol relative to enhanced clinical needs associated with the systemic inflammatory response, coined as the 'disproportion principle', may operate in RA. Although the underlying mechanisms are unknown, both proinflammatory cytokines and chronic stress may contribute the most in the adrenals hyporesponsiveness and the target tissue glucocorticoid resistance that have been described, but not systematically studied. A precise longitudinal assessment of endogenous cortisol production may be needed for optimal RA management.

CONCLUSION

Apart from iatrogenic AI, an intrinsically compromised adrenal reserve in RA may have a pathogenetic role and interfere with effective management, thus deserving further research.

Additive Interaction of Work-Related Stress and Sleep Duration on Arthritis Among Middle-Aged Civil Servants

Aim

Occupational strain is recognized as a risk for arthritis, yet little is known about how psychological stress affects arthritis moderated by sleep duration. The objective of this study is to assess work-related stress using the effort-reward imbalance (ERI) model and the job-demand-support (JDS) model on arthritis moderated by sleep duration.

Methods

A nationwide cross-sectional study randomly collected a total of 11,875 middle-aged, employed civil servants from 647 registered governmental institutions. Each participant anonymously and voluntarily filled out a web-based questionnaire and informed consent at the time of the study. Psychosocial work stress was assessed by ERI and JDS measured by a Chinese version of the job content questionnaire.

Results

There were significant odds ratios (ORs) of arthritis positively associated with high ERI (OR = 1.58), high overcommitment (OC) (OR = 1.57), and job demand (OR = 1.31) and negatively associated with job support (OR = 0.69) using multivariate analysis after being adjusted for covariates. For the short sleep duration group, there was an interaction effect of both high ERI and OC on arthritis, with a synergy index of 18.91 and 1.52, respectively. Similarly, there are high ORs of arthritis in both the high job demand and low job support groups.

Conclusion

Work-related stress related to arthritis moderated by sleep duration for civil servants. Civil servants with high job demand and low job support should use caution to reduce the risk of arthritis.

The Association Between Mental Health Disorders and Non-Infectious Scleritis: A Prevalence Study and Review of the Literature

Chronic inflammatory diseases can cause significant psychosocial stress in affected patients. Few studies have examined the psychological effects of ocular inflammatory disease and no studies have examined the psychological effects of scleritis. In this study we evaluate the prevalence of mental health disorders in scleritis patients and we conduct a comprehensive review of the literature on the mental health effects of ocular inflammatory diseases. 162 patients (195 eyes) presenting to a tertiary care center with scleritis were identified. At least one comorbid mental health disorder was diagnosed in 35 patients (21.6%), most commonly major depression in 11.7%, generalized anxiety disorder in 9.3%, and substance use disorder in 6.2%. There were no significant differences in the length of an episode of scleritis or in the probability of symptom resolution between patients with a mental health disorder and other patients. In a review of the literature, 30 manuscripts met the inclusion criteria. The majority of manuscripts (83.3%) were focused on uveitis patients. Eight of these studies were focused on patients with uveitis in the context of systemic disease. The most commonly reported mental health disorders reported were anxiety and depression. An average of 31.3% of patients with ocular inflammatory disease had depression and 35.0% had anxiety. Similar to other chronic illnesses, ocular inflammatory disease may be a significant psychosocial stressor. Future studies will further elucidate the relationship between these diseases and mental health.

Glucocorticoid resistance and β2-adrenergic receptor signaling pathways promote peripheral pro-inflammatory conditions associated with chronic psychological stress: A systematic review across species

Activation of the HPA-axis and SNS are widely accepted to link chronic stress with elevated levels of peripheral pro-inflammatory markers in blood. Yet, empirical evidence showing that peripheral levels of glucocorticoids and/or catecholamines mediate this effect is equivocal. Recent attention has turned to the possibility that cellular sensitivity to these ligands may contribute to inflammatory mediators that accompany chronic stress. We review current evidence for the association of chronic stress with glucocorticoid receptor (GR) and β-adrenergic receptor (β-AR) signaling sensitivity. Across 15 mouse, 7 primate, and 19 human studies, we found that chronic stress reliably associates with downregulation in cellular GR sensitivity, alterations in intracellular β-AR signaling, and upregulation in pro-inflammatory biomarkers in peripheral blood. We also present evidence that alterations in GR and β-AR signaling may be specific to myeloid progenitor cells such that stress-related signaling promotes release of cells that are inherently less sensitive to glucocorticoids and differentially sensitive to catecholamines. Our findings have broad implications for understanding mechanisms by which chronic stress may contribute to pro-inflammatory phenotypes.

Psychosomatic Features, Compliance and Complementary Therapies in Rheumatoid Arthritis

This review highlights the issue of psychosomatic conditions in rheumatoid arthritis, paying special attention to new researches and trends in this field. Emerging concepts in all the major parts of the problem are covered consecutively, from the impact of chronic musculoskeletal pain on the emotional state to disease influence over quality of life, socio-psychological, and interpersonal relationships. Chronic pain is closely related to emotional responses and coping ability, with a pronounced positive effect of psychotherapeutic interventions, family and social support on it. Psychosexual disorders, anxiety, depression also commonly coexist with rheumatoid arthritis, leading to further decrease in quality of life, low compliance, and high suicide risk. Influence of psychosomatic conditions on the overall treatment effect is usually underestimated by rheumatologists and general practitioners. Psychosomatic considerations are of great importance for up-to-date management of rheumatoid arthritis, as they strongly influence the quality of life, compliance, and thereby disease outcomes. Two major approaches of psychological rehabilitation exist, both coping with pain through the regulation of emotion and psychotherapeutic intervention, which not only helps patients in coping with the disease, but also aimed at improving the overall adaptation of the patient. It includes techniques of relaxation, cognitive-behavioral therapy, and biofeedback therapy. Current data about the efficacy of the additional correcting therapies for patients with rheumatoid arthritis, both emerging and common ones, are discussed in the review.

Prevalence Trend and Disparities in Rheumatoid Arthritis among US Adults, 2005-2018

Rheumatoid arthritis (RA) trends among US adults and disparities in RA patients in recent years have not been well described. We aimed to examine the trend of RA prevalence and disparities among US adults. Data from the National Health and Nutrition Examination Survey (NHANES) of the years 2005–2018 were analyzed to examine the self-reported RA prevalence trend. Age-adjusted RA prevalence stratified by race/ethnicity and socioeconomic status (SES), as well as associated linear trends, were calculated for both genders. The multivariable adjustment was used to evaluate the association between race, SES, and RA. During 2005–2018, there was no significant linear trend in the age-adjusted self-reported RA prevalence among men and women, but significant differences among people from different races, educational levels, and family poverty income ratio (PIR) groups were observed. The RA rate difference was significant for both genders and between Non-Hispanic Caucasians and Non-Hispanic African Americans (both p-value ≤ 0.001). Both men and women with a higher educational level and a higher PIR had a lower age-adjusted RA rate. Age-adjusted RA prevalence fluctuated for both men and women during 2005–2018. Non-Hispanic African Americans and people with low SES had significantly higher age-adjusted RA prevalence and RA risk.

Does the Interaction between Local and Systemic Inflammation Provide a Link from Psychology and Lifestyle to Tissue Health in Musculoskeletal Conditions?

Musculoskeletal conditions are known to involve biological, psychological, social and, often, lifestyle elements. However, these domains are generally considered in isolation from each other. This siloed approach is unlikely to be adequate to understand the complexity of these conditions and likely explains a major component of the disappointing effects of treatment. This paper presents a hypothesis that aims to provide a foundation to understand the interaction and integration between these domains. We propose a hypothesis that provides a plausible link between psychology and lifestyle factors with tissue level effects (such as connective tissue dysregulation/accumulation) in musculoskeletal conditions that is founded on understanding the molecular basis for interaction between systemic and local inflammation. The hypothesis provides plausible and testable links between mind and body, for which empirical evidence can be found for many aspects. We present this hypothesis from the perspective of connective tissue biology and pathology (fibrosis), the role of inflammation locally (tissue level), and how this inflammation is shaped by systemic inflammation through bidirectional pathways, and various psychological and lifestyle factors via their influence on systemic inflammation. This hypothesis provides a foundation for new consideration of the development and refinement of personalized multidimensional treatments for individuals with musculoskeletal conditions.

New Studies of Pathogenesis of Rheumatoid Arthritis with Collagen-Induced and Collagen Antibody-Induced Arthritis Models: New Insight Involving Bacteria Flora

Much public research suggests that autoimmune diseases such as rheumatoid arthritis (RA) are induced by aberrant “self” immune responses attacking autologous tissues and organ components. However, recent studies have reported that autoimmune diseases may be triggered by dysbiotic composition changes of the intestinal bacteria and an imbalance between these bacteria and intestinal immune systems. However, there are a few solid concepts or methods to study the putative involvement and relationship of these inner environmental factors in RA pathogenesis. Fortunately, Collagen-Induced Arthritis (CIA) and Collagen Antibody-Induced Arthritis (CAIA) models have been widely used as animal models for studying the pathogenesis of RA. In addition to RA, these models can be extensively used as animal models for studying complicated hypotheses in many diseases. In this review, we introduce some basic information about the CIA and CAIA models as well as how to apply these models effectively to investigate relationships between the pathogenesis of autoimmune diseases, especially RA, and the dysbiosis of intestinal bacterial flora.

Exacerbations of autoimmune diseases during pregnancy and postpartum

Autoimmune diseases represent a complex heterogeneous group of disorders that occur as a results of immune homeostasis dysregulation and loss of self-tolerance. Interestingly, more than 80% of the cases are found among women at reproductive age. Normal pregnancy is associated with remarkable changes in the immune and endocrine signaling required to tolerate and support the development and survival of the placenta and the semi-allogenic fetus in the hostile maternal immune system environment. Gravidity and postpartum represent an extremely challenge period, and likewise the general population, women suffering from autoimmune disorders attempt pregnancy. Effective preconception counseling and subsequent gestation and postpartum follow-up are crucial for improving mother and child outcomes. This comprehensive review provides information about the different pathways modulating autoimmune diseases activity and severity, such as the influence hormones, microbiome, infections, vaccines, among others, as well as updated recommendations were needed, in order to offer those women better medical care and life quality.

Association Between Noninfectious Uveitis and Psychological Stress

Importance

Uveitis involves dysregulation of the ocular immune system. Stress has been shown to affect immune function, but it is unclear whether there is an association between stress and uveitis.

Objective

To determine whether having uveitis is associated with psychological stress.

Design, Setting, and Participants

A cross-sectional, case-control study including a self-administered survey, medical records review, and diurnal salivary cortisol test was conducted at a university-based uveitis clinic and comprehensive eye clinic. Participants included 146 consecutive adults with noninfectious uveitis and age-matched controls with no eye disease. The study was conducted from December 1, 2017, to March 14, 2018.

Main Outcomes and Measures

Participants completed the self-administered, Cohen 10-item Perceived Stress Scale (PSS-10), a demographics questionnaire. Responses to each question were categorized on a 5-point Likert scale, with total scores ranging from 0 (no stress) to 40 (high stress). In addition, participants submitted 3 salivary cortisol samples. Those with uveitis were classified as having recently active or controlled disease through medical records review. The prespecified primary analysis was a linear regression of PSS-10 score and uveitis correcting for age, sex, educational level, employment, and median income. Secondary analyses included comparing PSS-10 scores in patients with recently active and controlled uveitis, determining predictors of stress, and comparing diurnal salivary cortisol between uveitis and control groups.

Results

Of 146 eligible patients, 17 declined participation and 9 consented but were excluded because they did not complete both questionnaires, resulting in 120 patients (80 uveitis; 40 controls) in the final analysis. Eighty participants (66.7%) were women, and 70 (58.3%) were white. Median age was 40 years (interquartile range, 29-59 years). Having uveitis was associated with a 4.3-point increase in PSS-10 score (95% CI, 1.8 to 6.9; P = .002). There was no significant difference in PSS-10 scores between patients with recently active and controlled uveitis (1.0 point greater for patients with active uveitis; 95% CI, -2.0 to 3.9; P = .52). Factors associated with increased PSS-10 score in patients with uveitis included female sex (coefficient, 4.0; 95% CI, 1.6 to 6.5; P = .002), current immunomodulatory therapy (coefficient, 2.5; 95% CI, -0.3 to 5.2; P = .08), history of depression (coefficient, 3.8; 95% CI, 0.8 to 6.8; P = .02), and having posterior or panuveitis (coefficient, 2.6; 95% CI, 0.8 to 4.4; P = .006). Of the 70 participants (58.3%) who had testable samples for cortisol analysis, diurnal salivary cortisol levels did not significantly differ between uveitis and nonuveitis groups.

Conclusions and Relevance

These findings suggest that patients with uveitis have higher levels of psychological stress compared with controls, yet no significant difference was identified in the stress of patients with active vs controlled uveitis. Consequently, comprehensive treatment for noninfectious uveitis may be able to address the psychological results of this disease.

A hot topic for health: Results of the Global Sauna Survey

OBJECTIVE

Sauna-bathing is an ancient tradition that is gaining popularity across the world as a wellness tool. There is a growing body of medical evidence supporting the role of saunas, or whole-body thermotherapy, as a form of treatment for a range of health issues. However, the demographics, motivations and experiences of current sauna bathers have not yet been explored on a global scale. This study is designed to explore these themes.

DESIGN

An online 71-item questionnaire compiling information on the individual characteristics, sauna-related habits and perceived health and wellness experiences of regular sauna bathers was conducted from October 2016 to October 2017. The validated 'SF-12' quality of life scoring tool was incorporated into the questionnaire to measure physical and mental indicators of well-being.

RESULTS

Of 572 logins recorded, 482 valid responses were generated. Both men (51.3%) and women (48.7%) were represented, and respondents were predominantly well-educated (81.8%), non-smoking (90.6%), regularly-exercising (78.8%) individuals of normal-to-overweight status (87.1%) who sauna-bathed approximately 1-2 times per week. The key reasons indicated by respondents for sauna-bathing included relaxation/stress reduction, pain relief and socializing. Nearly a third of respondents reported medical conditions and of this subset, those with back/musculoskeletal pain and mental issues cited the greatest improvements in their conditions with sauna-bathing. Of all respondents, 83.5% reported sleep benefits after sauna use. Analysis of well-being scores after stratifying respondents into three groups by sauna-bathing frequency (group I: <5 times per month; group II: 5-15 times per month; group III: >15 times per month) revealed group II respondents had slightly higher mental well-being scores (Kruskal-Wallis testing: H = 6.603 > ꭔ2 of 5.991, p = 0.0368, df = 2 with post hoc analysis using Mann-Whitney U test: p = 0.016) as compared to respondents who were sauna-bathing less frequently (group I). No respective differences were detected between the physical well-being scores of any of the three groups. Adverse reactions to sauna-bathing were recorded as mostly minor (93.1%), including primarily symptoms of dizziness, dehydration and headache. However, there were two reports (0.3%) of chest pain and eye irritation requiring hospitalization.

CONCLUSIONS

This cross-sectional study documents that sauna-bathing participants, particularly those from Finland, Australia and the United States, are motivated to use saunas predominantly for relaxation, reporting health benefits especially around mental well-being and sleep, with relatively few adverse effects. While these results reinforce some of the known health benefits of sauna bathing, they indicate that further research and better dissemination of existing evidence is needed to fully develop the sauna's potential as a therapeutic intervention.

Detection of systemic inflammation in severely impaired chronic pain patients and effects of a multimodal pain rehabilitation program

Background and aims

Recent research indicates a previously unknown low-grade systemic or neurogenic inflammation in groups of chronic pain (CP) patients. Low-grade inflammation may have an important role in symptoms that have previously not been well depicted: widespread pain, tiredness and cognitive dysfunctions frequently seen in severely impaired CP patients. This study aimed to investigate the plasma inflammatory profile in a group of very complex CP patients at baseline and at a 1-year follow-up after participation in a cognitive behavior therapy (CBT)-based multimodal pain rehabilitation program (PRP).

Methods

Blood samples were collected from 52 well-characterized CP patients. Age- and sex-matched healthy blood donors served as controls. The samples were analyzed with a multiple Proximal Extension Analysis allowing a simultaneous analysis of 92 inflammation-related proteins consisting mainly of cytokines, chemokines and growth-factors. At follow-up, 1-year after participation in the RPR samples from 28 patients were analyzed. The results were confirmed by a multi-array technology that allows quantitative estimation.

Results

Clear signs of increased inflammatory activity were detected in the CP patients. Accepting a false discovery rate (FDR) of 5%, there were significant differences in 43/92 inflammatory biomarkers compared with the controls. In three biomarkers (CXCL5, SIRT2, AXIN1) the expression levels were elevated more than eight times. One year after the PRP, with the patients serving as their own controls, a significant decrease in overall inflammatory activity was found.

Conclusions

Our results indicate that the most impaired CP patients suffer from low-grade chronic systemic inflammation not described earlier with this level of detail. The results may have implications for a better understanding of the cluster of co-morbid symptoms described as the “sickness-syndrome” and the wide-spread pain seen in this group of patients. The decrease in inflammatory biomarkers noted at the follow-up after participation in the PRP may reflect the positive effects obtained on somatic and psycho-social mechanisms involved in the inflammatory process by a rehabilitation program. Besides the PRP, no major changes in medication or lifestyle factors were implemented during the same period. To our knowledge, this is the first study reporting that a PRP may induce inflammatory-reducing effects. Further studies are needed to verify the objective findings in CP patients and address the question of causality that remains to be solved.

Implications

The findings offer a new insight into the complicated biological processes underlying CP. It may have implications for the understanding of symptoms collectively described as the “sickness-syndrome” – frequently seen in this group of patients. The lowering of cytokines after the participation in a PRP indicate a new way to evaluate this treatment; by measuring inflammatory biomarkers.

Does psychological stress in patients with clinically suspect arthralgia associate with subclinical inflammation and progression to inflammatory arthritis?

Background

Within established rheumatoid arthritis (RA), stress can have pro-inflammatory effects by activating the immune system via the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. It is unknown if stress levels also promote inflammation during RA development. We studied whether the psychological stress response was increased in clinically suspect arthralgia (CSA) and if this associated with inflammation at presentation with arthralgia and with progression to clinical arthritis.

Methods

In 241 CSA patients, psychological stress was measured by the Mental Health Inventory (MHI-5) and the Perceived Stress Scale (PSS-10) at first presentation and during follow-up. Systemic inflammation was measured by C-reactive protein (CRP) and joint inflammation by 1.5 T-MRI of wrist, MCP, and MTP joints.

Results

At baseline, 12% (24/197) of CSA patients had a high psychological stress response according to the MHI-5. This was not different for patients presenting with or without an elevated CRP, with or without subclinical MRI-detected inflammation and for patients who did or did not develop arthritis. Similar findings were obtained with the PSS-10. When developing clinical arthritis, the percentage of patients with ‘high psychological stress’ increased to 31% (p = 0.025); during the first year of treatment this decreased to 8% (p = 0.020). ‘High psychological stress’ in non-progressors remained infrequent over time (range 7–13%). Stress was associated with fatigue (p = 0.003) and wellbeing (p < 0.001).

Conclusions

Psychological stress was not increased in the phase of arthralgia, raised at the time of diagnoses and decreased thereafter. The lack of an association with inflammation in arthralgia and this temporal relationship, argue against psychological stress having a significant contribution to progression from CSA to inflammatory arthritis.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1587-y) contains supplementary material, which is available to authorized users.

Development of glucocorticoid resistance over one year among mothers of children newly diagnosed with cancer

Chronic distress associates with peripheral release of cortisol and a parallel upregulation of innate inflammation. Typically, cortisol functions to down-regulate inflammatory processes. However, in the context of chronic stress, it is hypothesized that glucocorticoid receptors within immune cells become less sensitive to the anti-inflammatory effects of cortisol, resulting in increased systemic inflammation. Caring for a child newly diagnosed with cancer is a particularly provocative chronic stressor. Here, we examine evidence for the development of cellular resistance to glucocorticoids among 120 mothers (Aged 18-56 years; 86% Caucasian) across the 12 months following their child's new diagnosis with cancer. Measures of psychological distress, interleukin (IL)-6, and glucocorticoid resistance (GCR) were assessed 1, 6, and 12 months after the diagnosis. A latent factor for distress was derived from the covariation among symptoms of anxiety, depression, and post-traumatic stress. Latent change score models revealed a significant positive association between change in distress and change in GCR from 0 to 6 months, and 6 months-1 year. This finding provides initial evidence for a longitudinal association between change in maternal distress and change in GCR from the onset of a chronic stressor through one year. Although levels of IL-6 increased during the first six months after the child's diagnosis, the magnitude of this change was not related to change in distress or change in GCR. Given the possible health consequences of reduced immune sensitivity to glucocorticoids, future work should further explore this stress response and its clinical significance.

[The specific features of the psycho-emotional status and the application of psychotherapy for the rehabilitative treatment of the patients presenting with rheumatoid arthritis]

The relevance of the problem of rheumatoid arthritis arises from the influence of such factors as its prevalence rate, unpredictability, tendency towards the transition to the chronic form, severe pain syndrome, high levels of disability, and long-term loss of working ability, as well as the accompanying psycho-emotional disorders. The present reviews article was designed to analyze the premorbid personality characteristics, the specifics features of mental health, and the response to the disease in the patients presenting with rheumatoid arthritis. Special emphasis is placed on the discusses of the relationship between the intensity of the pain syndrome and psycho-emotional disorders. The factors responsible for the development of the depressive states associated with rheumatoid arthritis are distinguished; they are shown to be related to both pathogenesis and the clinical symptoms of the underlying pathology as well as the general course of the disease and the specific features of the patients' psychological condition. The most extensively applied psychodiagnostics techniques are described, and the commonest psychotherapeutic approaches to the combined therapy and rehabilitation of the patients presenting with rheumatoid arthritis are overviewed.

The Importance of Mental Well-Being for Health Professionals During Complex Emergencies: It Is Time We Take It Seriously

We call on humanitarian aid organizations to integrate proven mental health strategies to protect the mental health of their workforce and improve staff capacity to provide care for vulnerable populations. Such strategies could include: Pre-deployment training Art therapy Team building Physical exercise Mindfulness or contemplative techniques Mind-body exercises Narrative Exposure Therapy Eye movement desensitization and reprocessing

[Chronic stress and mental disorders in patients with systemic scleroderma: Results of an interdisciplinary study]

AIM

To analyze of the prevalence of stressful factors and mental disorders (MDs), as well as their clinical psychopathological and clinical psychological characteristics to improve the comprehensive diagnosis and treatment of systemic scleroderma (SSD).

SUBJECTS AND METHODS

Examinations were performed in 110 patients (predominantly women (n=97 (88.2%); mean age, 49.9±2.47 years) with a documented diagnosis of SSD (its mean duration, 7.25±0.42 years). 62 (56.4%) patients had limited SSD, 36 (32.7%) had diffuse SSD, and 12 (10.9%) had overlap syndrome. The disease was rapidly and slowly progressive in 33 (30%) and 77 (70%) patients, respectively. Oral glucocorticosteroids were used in 99 (90%) patients included in the study, cytotoxic drugs in 66 (60%), plaquenil in 33 (30%); 8 (7%) patients were treated with the biological agent rituximab. All the patients were examined by a psychologist and a psychiatrist. The psychopathological diagnosis of MD was made during a semistructured interview in accordance with the ICD-10 criteria. The Montgomery-Asberg depression and Hamilton anxiety rating scales were used to evaluate the severity of depression and anxiety, respectively. All patients underwent a clinical and psychological examination, including tests assessing memory, attention, and logical thinking, as well as projective techniques.

RESULTS

MDs were detected in 91 (83%) patients with SSD. There was a preponderance of depressive disorders in 74 (67.3%) patients: chronic (dysthymia in 33 (30%) patients)) and recurrent (recurrent depressive disorder in 34 (31%)) depressions. Cognitive impairment (CI) of varying severities was diagnosed in 100% of the patients. Schizotypal personality disorder was stated in 44 (40%) patients. 90% of patients were found to have chronic psychic traumas mainly as parental deprivation in childhood (in children less than 11 years of age). 76.7% of the SSD cases developed recurrent episodes of depression in the presence of long-term MD or had a history of the episodes. There was no relationship of MD to gender, age, duration of SSD and its individual clinical manifestations. The nature of SSD treatment did not affect the frequency and spectrum of MD.

CONCLUSION

MDs, predominantly chronic and recurrent depression, and CI are characteristic of most SSD patients. Multiple chronic stressful factors, both previous SSD and those over time, have commonly an impact on the mental health of patients with SSD.

Life Stress and Health: A Review of Conceptual Issues and Recent Findings

Life stress is a central construct in many models of human health and disease. The present article reviews research on stress and health, with a focus on (a) how life stress has been conceptualized and measured over time, (b) recent evidence linking stress and disease, and (c) mechanisms that might underlie these effects. Emerging from this body of work is evidence that stress is involved in the development, maintenance, or exacerbation of several mental and physical health conditions, including asthma, rheumatoid arthritis, anxiety disorders, depression, cardiovascular disease, chronic pain, human immunodeficiency virus/AIDS, stroke, and certain types of cancer. Stress has also been implicated in accelerated biological aging and premature mortality. These effects have been studied most commonly using self-report checklist measures of life stress exposure, although interview-based approaches provide a more comprehensive assessment of individuals' exposure to stress. Most recently, online systems like the Stress and Adversity Inventory (STRAIN) have been developed for assessing lifetime stress exposure, and such systems may provide important new information to help advance our understanding of how stressors occurring over the life course get embedded in the brain and body to affect lifespan health.

Diagnostic value of high-frequency ultrasound and magnetic resonance imaging in early rheumatoid arthritis

Early diagnosis and management improve the outcome of patients with rheumatoid arthritis (RA). The present study explored the application of high-frequency ultrasound (US) and magnetic resonance imaging (MRI) in the detection of early RA. Thirty-nine patients (20 males and 19 females) diagnosed with early RA were enrolled in the study. A total of 1,248 positions, including 858 hand joints and 390 tendons, were examined by high-frequency US and MRI to evaluate the presence of bone erosion, bone marrow edema (BME), synovial proliferation, joint effusion, tendinitis and tendon sheath edema. The imaging results of the above abnormalities, detected by US, were compared with those identified using MRI. No statistically significant overall changes were observed between high-frequency US and MRI in detecting bone erosion [44 (5.1%) vs. 35 (4.1%), respectively; P>0.05], tendinitis [18 (4.6%) vs. 14 (1.5%), respectively; P>0.05] and tendon sheath edema [37 (9.5%) vs. 30 (7.7%), respectively; P>0.05]. Significant differences were observed between high-frequency US and MRI with regards to the detection of synovial proliferation [132 (15.4%) vs. 66 (7.7%), respectively; P<0.05] and joint effusion [89 (10.4%) vs. 52 (6.1%), respectively; P<0.05]. In addition, significant differences were identified between the detection of BME using MRI compared with high-frequency US (5.5 vs. 0%, respectively; P<0.05). MRI and high-frequency US of the dominant hand and wrist joints were comparably sensitive to bone erosion, tendinitis and tendon sheath edema. However, MRI was more sensitive in detecting bone marrow edema in early RA, while US was more sensitive in the evaluation of joint effusion and synovial proliferation. In conclusion, US and MRI are promising for the detection and diagnosis of inflammatory activity in patients with RA.

The role of the prolactin/vasoinhibin axis in rheumatoid arthritis: an integrative overview

Rheumatoid arthritis (RA) is a chronic, autoimmune, inflammatory disease destroying articular cartilage and bone. The female preponderance and the influence of reproductive states in RA have long linked this disease to sexually dimorphic, reproductive hormones such as prolactin (PRL). PRL has immune-enhancing properties and increases in the circulation of some patients with RA. However, PRL also suppresses the immune system, stimulates the formation and survival of joint tissues, acquires antiangiogenic properties upon its cleavage to vasoinhibins, and protects against joint destruction and inflammation in the adjuvant-induced model of RA. This review addresses risk factors for RA linked to PRL, the effects of PRL and vasoinhibins on joint tissues, blood vessels, and immune cells, and the clinical and experimental data associating PRL with RA. This information provides important insights into the pathophysiology of RA and highlights protective actions of the PRL/vasoinhibin axis that could lead to therapeutic benefits.

Bidirectional associations between rheumatoid arthritis and depression: a nationwide longitudinal study

Rheumatoid arthritis (RA) and depression may be associated with each other pathophysiologically, but few studies have been conducted on the interplay between these two diseases using longitudinal measurement. Therefore, we used the National Health Insurance Research Database of Taiwan to investigate the bidirectional associations between RA and depression. One cohort was included to analyze RA predicting the onset of depression and a second cohort for analysis of depression predicting RA. A sex- and age-matched control group was included for both. The incidence of depression in RA subjects was higher than in non-RA subjects [15.69 vs. 8.95 per 1,000 person-years (PYs)], with an adjusted hazard ratios (HRs) of 1.69 [95% confidence interval (CI), 1.51-1.87]. The incidence of RA was higher in depressed than non-depressed individuals (2.07 vs. 1.21 per 1,000 PYs), with an adjusted HRs of 1.65 (95% CI, 1.41-1.77). This population-based cohort study suggested strong bidirectional relationships between RA and depression. Healthcare providers are recommended to facilitate the implementation of more effective therapeutic interventions to achieve favorable prognosis, especially for those with new-onset or younger cases.

Efficacy & safety evaluation of Ayurvedic treatment (Ashwagandha powder & Sidh Makardhwaj) in rheumatoid arthritis patients: a pilot prospective study

BACKGROUND & OBJECTIVES

In the traditional system of medicine in India Ashwagandha powder and Sidh Makardhwaj have been used for the treatment of rheumatoid arthritis. However, safety and efficacy of this treatment have not been evaluated. Therefore, the present study was carried out to evaluate the efficacy and safety of Ayurvedic treatment (Ashwagandha powder and Sidh Makardhwaj) in patients with rheumatoid arthritis.

METHODS

One hundred and twenty five patients with joint pain were screened at an Ayurvedic hospital in New Delhi, India. Eighty six patients satisfied inclusion criteria and were included in the study. Detailed medical history and physical examination were recorded. Patients took 5g of Ashwagandha powder twice a day for three weeks with lukewarm water or milk. Sidh Makardhwaj (100 mg) with honey was administered daily for the next four weeks. The follow up of patients was carried out every two weeks. The primary efficacy end point was based on American College of Rheumatology (ACR) 20 response. Secondary end points were ACR50, ACR70 responses, change from baseline in disease activity score (DAS) 28 score and ACR parameters. Safety assessments were hepatic function [alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), bilirubin and ß2 microglobulin], renal function (urea and creatinine and NGAL) tests and urine mercury level.

RESULTS

The study was completed by 90.7 per cent (78/86) patients. Patients with moderate and high disease activity were 57.7 per cent (45/78) and 42.3 per cent (33/78), respectively. All patients were tested positive for rheumatoid factor and increased ESR level. Ashwagandha and Sidh Makardhwaj treatment decreased RA factor. A significant change in post-treatment scores of tender joint counts, swollen joint counts, physician global assessment score, patient global assessment score, pain assessment score, patient self assessed disability index score and ESR level were observed as compared to baseline scores. ACR20 response was observed in 56.4 per cent (44/78) patients (American College of Rheumatology criteria) and moderate response in 39.74 per cent (31/78) patients [European League Against Rheumatism (EULAR) criteria]. Ayurvedic treatment for seven weeks in rheumatoid arthritis patients showed normal kidney and liver function tests. However, increased urinary mercury levels were was observed after treatment.

INTERPRETATION & CONCLUSIONS

The findings of the present study suggest that this Ayurvedic treatment (Ashwagandha powder and Sidh Makardhwaj) has a potential to be used for the treatment of rheumatoid arthritis. However, due to small sample size, short duration, non randomization and lack of a control group as study limitations, further studies need to be done to confirm these findings.

Life events, emotional responsiveness, and the functional prognosis of patients with rheumatoid arthritis

Background

Stressors may differently affect human physiological systems according to the host properties relevant to psycho-behavioral processes that the stressors invoke. In a Japanese multicenter cohort study of patients with rheumatoid arthritis (RA), we examined if major life events differently contribute to the patients’ functional prognosis according to their ability to identify emotions as manifest feelings when encountering the events (emotional responsiveness).

Methods

460 patients with RA completed a self-administered baseline questionnaire about psychosocial factors including emotional responsiveness. Two years later, they checked on a list of positive/negative personal events that happened during the two-year study period. Rheumatologists evaluated their functional status at baseline and follow-up using the ACR classification system.

Results

In a multiple logistic regression model that included baseline demographic, disease activity/severity-related, therapeutic, and socioeconomic factors as covariates, none of the counts of positive, negative, or all life events was associated with the functional status at follow-up. In the subgroup with poor emotional responsiveness, however, these life event counts were all associated with a poorer functional prognosis (odds ratio of ACR class 3–4 vs. 1–2 associated with one increment in the all life-event count = 2.39, 95 % confidence interval = 1.27-4.48, p = .007), while no such relationship was evident for the rest of the patients.

Conclusions

Major life events, whether positive or negative in nature, may have an impact on the disease course of patients with RA when the patient has poor emotional responsiveness to the event(s).

Prevalence of and risk factors associated with dry eye: the Korea National Health and Nutrition Examination Survey 2010-2011

PURPOSE

To investigate the prevalence of and risk factors associated with dry eye syndrome (DES) in South Korea.

DESIGN

Cross-sectional study.

METHODS

In 2010 and 2011, 11,666 subjects, ranging in age from 19 to 95, were randomly selected as nationally representative participants in the Korea National Health and Nutrition Examination Survey (KNHANES). Subjects were divided into 2 groups: 1 with clinically diagnosed DES and 1 with symptoms of dry eye. We determined the prevalence of and risk factors for dry eyes in a Korean population. Health-related quality of life (HRQoL), measured by the EuroQoL-5 dimension (EQ-5D), was evaluated in patients with dry eyes.

RESULTS

The mean age was 49.9 years. The overall prevalence of diagnosed DES was 8.0% (95% confidence interval [CI], 7.3% to 8.7%), and of dry eye symptoms the prevalence was 14.4% (95% CI, 13.1 to 15.7). Age (adjusted odds ratio [aOR] = 1.8, 1.6), female (aOR = 2.8, 1.9); history of eye surgery (aOR = 2.6, 2.2); stress (aOR = 1.7, 1.6); thyroid disease (aOR = 1.7, 1.5); and high education level (aOR = 1.6, 1.5) were common risk factors in the groups. Subjects who had undergone ptosis, cataract or refractive surgery were more likely to have dry eye than subjects with no history of eye surgery. Means of pain and anxiety dimensions in the EQ-5D and the Euro Quality of Life Visual Analog Scale (EQ-VAS) were significantly higher in the group with diagnosed DES than in the normal group.

CONCLUSIONS

The risk factors were mostly similar in both groups. It is thought there are more patients with DES who have not been diagnosed by doctors. Doctors should identify whether a patient has any risk factors for dry eye. Patients need to be educated about the modifiable factors of DES.

Immune responses to stress after stress management training in patients with rheumatoid arthritis

Introduction

Psychological stress may alter immune function by activating physiological stress pathways. Building on our previous study, in which we report that stress management training led to an altered self-reported and cortisol response to psychological stress in patients with rheumatoid arthritis (RA), we explored the effects of this stress management intervention on the immune response to a psychological stress task in patients with RA.

Methods

In this study, 74 patients with RA, who were randomly assigned to either a control group or a group that received short stress management training, performed the Trier Social Stress Test (TSST) 1 week after the intervention and at a 9-week follow-up. Stress-induced changes in levels of key cytokines involved in stress and inflammatory processes (for example, interleukin (IL)-6 and IL-8) were assessed.

Results

Basal and stress-induced cytokine levels were not significantly different in patients in the intervention and control groups one week after treatment, but stress-induced IL-8 levels were lower in patients in the intervention group than in the control group at the follow-up assessment.

Conclusions

In line with our previous findings of lower stress-induced cortisol levels at the follow-up of stress management intervention, this is the first study to show that relatively short stress management training might also alter stress-induced IL-8 levels in patients with RA. These results might help to determine the role of immunological mediators in stress and disease.

Trial registration

The Netherlands National Trial Register (NTR1193)

Immune responses to stress in rheumatoid arthritis and psoriasis

OBJECTIVE

Stress is one of the factors that may exacerbate the progression of chronic inflammatory diseases such as RA and psoriasis. We exploratively compared the effects of acute stress on levels of circulating cytokines involved in disease progression and/or the stress response in patients with RA, patients with psoriasis and healthy subjects.

METHODS

Patients with RA, patients with psoriasis and healthy controls underwent a standardized psychosocial stress test (Trier Social Stress Test). Levels of circulating cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IFN-γ and TNF-α) were measured before and after the stress test.

RESULTS

The baseline levels of all cytokines, except IL-8, were significantly higher in patients with RA. After correction for baseline levels, patients with RA showed higher stress-induced levels of IL-1β and IL-2 than patients with psoriasis and healthy controls.

CONCLUSION

The results suggest that patients with RA have a different immune response to stress than patients with psoriasis or healthy controls. More needs to be learned about the complex interaction between stress, immune parameters and chronic inflammation.

Neuropeptide Y induces potent migration of human immature dendritic cells and promotes a Th2 polarization

Neuropeptide Y (NPY), a major autonomic nervous system and stress mediator, is emerging as an important regulator of inflammation, implicated in autoimmunity, asthma, atherosclerosis, and cancer. Yet the role of NPY in regulating phenotype and functions of dendritic cells (DCs), the professional antigen-presenting cells, remains undefined. Here we investigated whether NPY could induce DCs to migrate, mature, and polarize naive T lymphocytes. We found that NPY induced a dose-dependent migration of human monocyte-derived immature DCs through the engagement of NPY Y1 receptor and the activation of ERK and p38 mitogen-activated protein kinases. NPY promoted DC adhesion to endothelial cells and transendothelial migration. It failed to induce phenotypic DC maturation, whereas it conferred a T helper 2 (Th2) polarizing profile to DCs through the up-regulation of interleukin (IL)-6 and IL-10 production. Thus, during an immune/inflammatory response NPY may exert proinflammatory effects through the recruitment of immature DCs, but it may exert antiinflammatory effects by promoting a Th2 polarization. Locally, at inflammatory sites, cell recruitment could be amplified in conditions of intense acute, chronic, or cold stress. Thus, altered or amplified signaling through the NPY-NPY-Y1 receptor-DC axis may have implications for the development of inflammatory conditions.-Buttari, B., Profumo, E., Domenici, G., Tagliani, A., Ippoliti, F., Bonini, S., Businaro, R., Elenkov, I., Riganò, R. Neuropeptide Y induces potent migration of human immature dendritic cells and promotes a Th2 polarization.

Rational/antiemotional behaviors in interpersonal relationships and the functional prognosis of patients with rheumatoid arthritis: a Japanese multicenter, longitudinal study

Background

The repression of negative emotions is a personality factor that received considerable attention in the 1950-60s as being relevant to the onset and course of rheumatoid arthritis (RA). Despite subsequent, repeated criticisms of the cross-sectional nature of the earlier studies, even to date few prospective studies have been reported on this issue. This multicenter study prospectively examined if “rational and antiemotional” behavior (antiemotionality), characterized by an extreme tendency to suppress emotional behaviors and to rationalize negative experiences in conflicting interpersonal situations, is associated with the functional prognosis of patients with RA.

Methods

532 patients with RA who regularly visited one of eight hospitals/clinics in Japan in 2000 were recruited for study. All completed a self-administered baseline questionnaire about lifestyle and psychosocial factors including antiemotionality. Two years after, 460 (mean age, 56.1 years; 54 men and 406 women) of 471 patients who continued to visit the clinics agreed to take the follow-up questionnaire. The functional status of the patients was evaluated by rheumatologists based on the ACR classification system.

Results

A multiple logistic regression model that included baseline demographic, disease activity/severity-related, therapeutic, and socioeconomic factors as covariates found a tendency toward higher antiemotionality to be related to poorer functional status at follow-up. This relationship was not explained by lifestyle factors.

Conclusions

Antiemotionality may be a prognostic factor for the functional status of patients with RA. This finding sheds light on a seemingly forgotten issue in the care of patients with RA.

Nerve-derived transmitters including peptides influence cutaneous immunology

Clinical observations suggest that the nervous and immune systems are closely related. For example, inflammatory skin disorders; such as psoriasis, atopic dermatitis, rosacea and acne; are widely believed to be exacerbated by stress. A growing body of research now suggests that neuropeptides and neurotransmitters serve as a link between these two systems. Neuropeptides and neurotransmitters are released by nerves innervating the skin to influence important actors of the immune system, such as Langerhans cells and mast cells, which are located within close anatomic proximity. Catecholamines and other sympathetic transmitters that are released in response to activation of the sympathetic nervous system are also able to reach the skin and affect immune cells. Neuropeptides appear to direct the outcome of Langerhans cell antigen presentation with regard to the subtypes of Th cells generated and neuropeptides induce the degranulation of mast cells, among other effects. Additionally, endothelial cells, which release many inflammatory mediators and express cell surface molecules that allow leukocytes to exit the bloodstream, appear to be regulated by certain neuropeptides and transmitters. This review focuses on the evidence that products of nerves have important regulatory activities on antigen presentation, mast cell function and endothelial cell biology. These activities are highly likely to have clinical and therapeutic relevance.

The influence of perceived stress on the onset of arthritis in women: findings from the Australian Longitudinal Study on women's health

BACKGROUND

Psychosocial factors are considered as risk factors for some chronic diseases. A paucity of research exists surrounding the role of perceived stress in arthritis onset.

PURPOSE

Perceived stress as a risk factor for arthritis development was explored in an ageing cohort of Australian women.

METHODS

This study focused on 12,202 women from the 1946-1951 cohort who completed the Australian Longitudinal Study on Women's Health surveys in 2001, 2004 and 2007. Longitudinal associations were modelled, with and without a time lag.

RESULTS

Findings from the multivariate time lag modelling, excluding women with persistent joint pain, revealed that perceived stress predicted the onset of arthritis, with women experiencing minimal and moderate/high stress levels having a 1.7 and 2.4 times greater odds of developing arthritis 3 years later, respectively (p's < 0.001).

CONCLUSION

Chronically perceiving life as stressful is detrimental to future health. The findings provide support for perceived stress to be considered alongside other modifiable risk factors.

Gender-specific association between childhood trauma and rheumatoid arthritis: a case-control study

OBJECTIVE

Rheumatoid arthritis (RA) has been associated with a variety of emotional stressors, but findings remain inconclusive if RA is related to childhood trauma, which is known to have long-lasting negative consequences for physical health decades into adulthood. We investigated the association between childhood trauma and RA by comparing histories of child abuse and neglect between RA patients and adults from the general population in a cross-sectional case-control study.

METHODS

331 patients with definite RA and 662 gender- and age-matched adults from the general population were administered the self-report Childhood Trauma Questionnaire (CTQ) for the assessment of emotional, physical and sexual abuse as well as emotional and physical neglect.

RESULTS

Adjusting for gender and current depression, RA patients scored significantly higher in all CTQ subscales apart from sexual abuse and physical neglect than the controls. Adjusted odds ratios for these types of childhood trauma were higher in the RA group than in controls ranging from 2.0 for emotional neglect (95% confidence interval [CI]: 1.4-3.0) to 2.6 for emotional abuse (95% CI: 1.4-4.7). Gender-specific analyses revealed basically the same pattern for women, but not for men.

CONCLUSION

Our findings suggest an association between childhood trauma and development of RA, particularly in women. This relationship may be mediated by dysregulations of neuro-endocrine-immune networks, but larger prospective studies are needed to clarify the association between early life stress and the risk for RA in genetically susceptible individuals.

Rheumatoid arthritis in the elderly and its relationship with periodontitis: a review

Periodontitis and rheumatoid arthritis are chronic inflammatory diseases commonly seen in the elderly. It has been proposed that the two conditions are interrelated and influence the severity of each other. Recently, the role of Porphyromonas gingivalis, a periodontopathogen, has been explained in the pathogenesis and progression of rheumatoid arthritis. It can be inferred from the present review that the two conditions share a common pathobiology, genetics and environmental risk factors. Furthermore, a thorough understanding of the aforementioned mechanisms might enable the development of conjoint treatment modalities beneficial in treating the geriatric population afflicted by both the disorders.

Possible rheumatoid arthritis subtypes in terms of rheumatoid factor, depression, diagnostic delay and emotional expression: an exploratory case-control study

Introduction

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis has been implicated in the pathology of rheumatoid arthritis (RA), particularly as vulnerable personality types are exposed to chronic stress. Emotions are powerful modulators of stress responses. However, little is known about whether patients with RA process emotions differently to matched controls. In this study we: 1) assessed whether the trait emotional intelligence (trait EI) scores of patients with RA differ from healthy controls at the facet level; 2) explored any subgroups in RA, in terms of trait EI and common risk factors.

Methods

A total of 637 patients with RA were compared to 496 controls on the trait EI Questionnaire (TEIQue). RA subgroups were explored in terms of trait EI, rheumatoid factor status (RF+/-), depression and time from onset of symptoms until diagnosis (diagnostic delay).

Results

The RA group rated themselves lower on Adaptability, Stress-management, Emotion management, Self-esteem, Sociability, Assertiveness, Impulsiveness and Well-being, and higher on Empathy and Relationships than healthy controls. The RF- subtype reported more time with depression (25.2 vs. 11.3 months), a longer diagnostic delay (3.0 vs. 1.7 years), and greater emotional expression (5.15 vs. 4.72), than the RF+ subtype. These differences were significant at the P <0.05 level, but not following strict Bonferroni corrections and should therefore be treated as indicative only. RF- patients with a longer diagnostic delay reported depression lasting three times longer (42.7 months), when compared to three other subtypes (11.0 to 12.7 months).

Conclusions

RA patients and controls differ in their emotion-related personality traits, as operationalized by trait EI. These differences may make people with RA more susceptible to chronic stress and HPA-axis dysregulation. RA may be a highly heterogeneous illness where at least two subtypes may be characterized by personality, psychiatric and immunological differences. RF- status, as well as diagnostic delay and emotional expression, may predict future risk of depression. Research on the causes of RA could benefit from a systems science approach.

Differential effect of severe and moderate social stress on blood immune and endocrine measures and susceptibility to collagen type II arthritis in male rats

The effects of social stress on several blood immune measures and collagen-induced arthritis (CIA) were investigated in Wistar rats using the resident-intruder confrontation paradigm to induce stress of different intensity. Male intruders were exposed for one week to a dominant opponent either repeatedly for 4h daily (moderate stress) or continuously (severe stress). Arthritis was induced by intradermal injection of collagen type II (CII) into the tail skin at the end of day 3 of confrontation. Only severe stress was associated with decreased CD4 and CD8 T cells, and the increase in granulocyte numbers and body mass loss was more pronounced under these conditions. Only severe stress reduced the susceptibility to arthritis by about 50%. Severity scores did not differ in the first five days after disease onset between all groups. Subsequent experiments focused on severely stressed rats indicated that disease progressed until day 10 only in control animals, but not in severely stressed males. Stressor exposure resulted in increased blood monocyte numbers, but these males failed to accumulate macrophages into the skin at the site of CII injection. High numbers of attacks experienced by intruders correlated with delayed disease onset in severely stressed rats. We hypothesize that severe stress persisting after disease induction exhibits beneficial effects on the susceptibility of CIA and propose that the specific endocrine and immunological profile associated with severe stress is an important factor for disease outcome--a factor which probably explains many of the conflicting data of previous stress studies on CIA.