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Cooke EJ, Joseph BC, Nasamran CA, Fisch KM, von Drygalski A. Maladaptive lymphangiogenesis is associated with synovial iron accumulation and delayed clearance in factor VIII-deficient mice after induced hemarthrosis. J Thromb Haemost 2023; 21:2390-2404. [PMID: 37116753 PMCID: PMC10792547 DOI: 10.1016/j.jtha.2023.04.022] [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: 02/22/2023] [Revised: 03/21/2023] [Accepted: 04/06/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Mechanisms of iron clearance from hemophilic joints are unknown. OBJECTIVES To better understand mechanisms of iron clearance following joint bleeding in a mouse model of hemophilia. METHODS Hemarthrosis was induced by subpatellar puncture in factor VIII (FVIII)-deficient (FVII-/-) mice, +/- periprocedural recombinant human FVIII, and hypocoagulable (HypoBALB/c) mice. HypoBALB/c mice experienced transient FVIII deficiency (anti-FVIII antibody) at the time of injury combined with warfarin-induced hypocoagulability. Synovial tissue was harvested weekly up to 6 weeks after injury for histological analysis, ferric iron and macrophage accumulation (CD68), blood and lymphatic vessel remodeling (αSMA; LYVE1). Synovial RNA sequencing was performed for FVIII-/- mice at days 0, 3, and 14 after injury to quantify expression changes of iron regulators and lymphatic markers. RESULTS Bleed volumes were similar in FVIII-/- and HypoBALB/c mice. However, pronounced and prolonged synovial iron accumulation colocalizing with macrophages and impaired lymphangiogenesis were detected only in FVIII-/- mice and were prevented by periprocedural FVIII. Gene expression changes involved in iron handling (some genes with dual roles in inflammation) and lymphatic markers supported proinflammatory milieu with iron retention and disturbed lymphangiogenesis. CONCLUSION Accumulation and delayed clearance of iron-laden macrophages were associated with defective lymphangiogenesis after hemarthrosis in FVIII-/- mice. The absence of such findings in HypoBALB/c mice suggests that intact lymphatics are required for removal of iron-laden macrophages and that these processes depend on FVIII availability. Studies to elucidate the biological mechanisms of disturbed lymphangiogenesis in hemophilia appear critical to develop new therapeutic targets.
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Affiliation(s)
- Esther J Cooke
- Division of Hematology/Oncology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Bilgimol C Joseph
- Division of Hematology/Oncology, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Chanond A Nasamran
- Center for Computational Biology and Bioinformatics, University of California San Diego, La Jolla, California, USA
| | - Kathleen M Fisch
- Center for Computational Biology and Bioinformatics, University of California San Diego, La Jolla, California, USA
| | - Annette von Drygalski
- Division of Hematology/Oncology, Department of Medicine, University of California San Diego, La Jolla, California, USA.
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2
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van Vulpen LFD, van Bergen EDP, Pulles AE, Mastbergen SC. The detrimental effects of iron to the joint; aggravation by inflammation. Haemophilia 2023; 29:365-366. [PMID: 36395784 DOI: 10.1111/hae.14696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/25/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Centre (UMC) Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Eline D P van Bergen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Centre (UMC) Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Rheumatology & Clinical Immunology, University Medical Center (UMC) Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Astrid E Pulles
- Department of Hematology, Cancer Center, University Medical Center (UMC) Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Simon C Mastbergen
- Department of Rheumatology & Clinical Immunology, University Medical Center (UMC) Utrecht, Utrecht University, Utrecht, the Netherlands
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Sun K, Guo Z, Hou L, Xu J, Du T, Xu T, Guo F. Iron homeostasis in arthropathies: From pathogenesis to therapeutic potential. Ageing Res Rev 2021; 72:101481. [PMID: 34606985 DOI: 10.1016/j.arr.2021.101481] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/25/2021] [Accepted: 09/29/2021] [Indexed: 02/08/2023]
Abstract
Iron is an essential element for proper functioning of cells within mammalian organ systems; in particular, iron homeostasis is critical for joint health. Excess iron can induce oxidative stress damage, associated with the pathogenesis of iron-storage and ageing-related diseases. Therefore, iron levels in body tissues and cells must be tightly regulated. In the past decades, excess iron content within joints has been found in some patients with joint diseases including hemophilic arthropathy, hemochromatosis arthropathy, and osteoarthritis (OA). Currently, increased evidence has shown that iron accumulation is closely associated with multiple pathological changes of these arthropathies. This review summarizes system-level and intracellular regulation of iron homeostasis, and emphasizes the role of iron in synovial alterations, cartilage degeneration, and subchondral bone of several arthropathies. Of note, we discuss the potential link between iron homeostasis and OA pathogenesis. Finally, we discuss the therapeutic potential of maintaining iron homeostasis in these arthropathies.
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Landro Carla Daffunchio Guillermo Cambiaggi Gustavo Galatro Horacio Caviglia ME, Daffunchio C, Cambiaggi G, Galatro GG, Caviglia H. Platelet-rich plasma vs platelet-rich plasma plus hyaluronic acid for haemophilic knee arthropathy treatment. Acta Orthop Belg 2021; 87:705-712. [PMID: 35172437 DOI: 10.52628/87.4.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Repeated joint bleeding leads to chronic synovitis, cartilage damage and bone alterations which result in haemophilic arthropathy and are associated with pain, functional impairment and poor quality of life. There are evidence that Hyaluronic Acid (HA) and Platelet-rich Plasma (PRP) have different mechanisms of action in the treatment of arthropathy for this reason we decided to use both components. The aim of this study is to compare, the efficacy, safety and duration of a single intra-articular injection of PRP against PRP+HA for pain, bleeding episodes and joint health, in the same patient with bilateral hemophilic knee arthropathy. Twenty-one men patients (42 knee joints) were treated with intra- articular injections of PRP or PRP+HA. All of them were haemophilia type A severe. The mean age was 36.6 years (21-72). All patients were evaluated for: Haemophilia Joint Health Score (HJHS), pain (VAS), the number of bleeding episodes (BE) in the last 30 days, before treatment, at three and six months after treatment. Statistically significant improvement were shown for both knee joints at three and six months after treatment for VAS and BE (P < 0.00001). The HJHS score did not significantly improve for either knee in the 6-month period after injection. A single PRP or PRP+HA injection is safe and effective in treating haemophilic arthropathy of the knee for up to 6 months follow-up, reducing pain, bleeding episodes and delaying total knee arthroplasty.
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Pulles AE, van Vulpen LFD, Coeleveld K, Mastbergen SC, Schutgens REG, Lafeber FPJG. On-demand treatment with the iron chelator deferasirox is ineffective in preventing blood-induced joint damage in haemophilic mice. Haemophilia 2021; 27:648-656. [PMID: 34043875 PMCID: PMC8361985 DOI: 10.1111/hae.14328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/01/2021] [Accepted: 04/16/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Early intervention in the devastating process of haemophilic arthropathy (HA) is highly desirable, but no disease-modifying therapy is currently available. Considering the pivotal role of iron in the development of HA, iron chelation is considered a promising therapeutic approach. A previous study in haemophilic mice demonstrated that treatment with the iron chelator deferasirox (DFX) 8 weeks before joint bleed induction, attenuated cartilage damage upon blood exposure. However, in haemophilia patients this approach is not opportune given the unpredictable occurrence of hemarthroses. AIM To evaluate the effectiveness of on-demand DFX treatment, initiated immediately after joint bleed induction. METHODS A joint bleed was induced in 66 factor VIII-deficient mice by infra-patellar needle puncture. Mice were randomly assigned to treatment with either placebo (drinking water) or DFX (dissolved in drinking water) throughout the study. Five weeks after joint bleed induction, inflammation and cartilage damage were assessed histologically. Joints of ten bleed naive haemophilic mice served as controls. RESULTS A joint bleed resulted in significant inflammation and cartilage damage in the blood-exposed joint compared with those of control animals, in both the placebo and DFX group (all p = <.05). No differences in tibiofemoral or patellar inflammation (p = .305 and p = .787, respectively) nor cartilage damage (p = .265 and p = .802, respectively) were found between the blood-exposed joints of both treatment groups. CONCLUSION On-demand treatment with DFX does not prevent joint damage following blood exposure in haemophilic mice. DFX seems unable to reach the joint in time to exert its effect before the irreversible harmful process is initiated.
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Affiliation(s)
- Astrid E. Pulles
- Department of Rheumatology & Clinical ImmunologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Lize F. D. van Vulpen
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Katja Coeleveld
- Department of Rheumatology & Clinical ImmunologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Simon C. Mastbergen
- Department of Rheumatology & Clinical ImmunologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Roger E. G. Schutgens
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Floris P. J. G. Lafeber
- Department of Rheumatology & Clinical ImmunologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
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Majeed H, Ahmed H, Sussman MS, Macgowan C, Rayner T, Weiss R, Feldman BM, Doria AS. Understanding Early Hemophilic Arthropathy in Children and Adolescents Through MRI T 2 Mapping. J Magn Reson Imaging 2020; 53:827-837. [PMID: 33135834 DOI: 10.1002/jmri.27406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Persons with hemophilia experience hemarthrosis, which can lead to cartilage degeneration, causing physical impairment. MRI T2 mapping has the potential to be used as a tool to evaluate early arthropathic changes and cartilage degeneration in patients with hemophilia. PURPOSE To assess the value of MRI-T2 mapping as a tool for investigating the cartilage status of children and adolescents with hemophilic arthropathy. STUDY TYPE Prospective, cross-sectional. SUBJECTS Twenty-eight boys with hemophilia (aged 5-17 years) and 23 healthy boys (aged 7-17 years). FIELD STRENGTH/SEQUENCES A multiecho spin-echo T2 -weighted gradient echo sequence was used on a 3.0T magnet. ASSESSMENT MRI-T2 maps of ankle (tibia-talus) (n = 19) or knee (femur-tibia) (n = 9) cartilage were assessed in hemophilia and healthy groups. An anatomically-based MRI score was also assigned to each ankle/knee. STATISTICAL TESTS Pearson's correlation coefficient (r), linear regression, intraclass correlation coefficient (ICC), and analysis of variance (ANOVA) test. RESULTS Negative associations between age and ankle/knee cartilage T2 relaxation times were found in hemophilia (r = -0.72 [P = 0.03] to -0.55 [P = 0.01]) and healthy (r = -0.84 [P < 0.001] to -0.55 [P = 0.20]) groups. There were nonsignificant associations between ankle cartilage T2 relaxation times and MRI scores (r = -0.15 [P = 0.54] to 0.31 [P = 0.19]). DATA CONCLUSION Results of this clinical investigation emphasize the potential importance of MRI-T2 maps as a tool to understand the functional status of cartilage in children and adolescents with hemophilic arthropathy, while holding promise for the detection of early cartilage degeneration prior to macroscopic characterization by conventional MRI. MRI-T2 mapping may provide novel information that is not reflected in the anatomically-based MRI scoring system. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Haris Majeed
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Humayun Ahmed
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Marshall S Sussman
- Department of Medical Imaging, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Christopher Macgowan
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tammy Rayner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ruth Weiss
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian M Feldman
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, Faculty of Medicine, Institute of Health Policy, Management & Evaluation, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Imaging, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
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Bertling A, Brodde MF, Visser M, Treffon J, Fennen M, Fender AC, Kelsch R, Kehrel BE. Components in Plasma-Derived Factor VIII, But Not in Recombinant Factor VIII Downregulate Anti-Inflammatory Surface Marker CD163 in Human Macrophages through Release of CXCL4 (Platelet Factor 4). Transfus Med Hemother 2017; 44:351-357. [PMID: 29070980 DOI: 10.1159/000472157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 03/22/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemarthrosis, or bleeding into the joints, is a hallmark of hemophilia. Heme triggers oxidative stress, inflammation, and destruction of cartilage and bone. The haptoglobin-CD163-heme oxygenase-1 (HO-1) pathway circumvents heme toxicity through enzymatic degradation of heme and transcription of antioxidant genes. Plasma-derived factor concentrates contain many proteins that might impact on cellular pathways in joints, blood, and vessels. METHODS Activation of platelets from healthy volunteers was assessed by flow cytometry analysis of fibrinogen binding and CD62P expression. Platelet CXCL4 release was measured by ELISA. Human peripheral blood mononuclear cells were exposed to CXCL4 or platelet supernatants (untreated or pre-stimulated with factor VIII (FVIII) products) during their differentiation to macrophages and analyzed for CD163 expression. Some macrophage cultures were additionally incubated with autologous hemoglobin for 18 h for analysis of HO-1 expression. RESULTS Platelet CXCL4 release was increased by all 8 tested plasma-derived FVIII products but not the 3 recombinant products. Macrophages exposed to supernatant from platelets treated with some plasma-derived FVIII products downregulated CD163 surface expression and failed to upregulate the athero- and joint protective enzyme HO-1 in response to hemoglobin. CONCLUSION Plasma-derived FVIII products might promote bleeding-induced joint injury via generation of macrophages that are unable to counteract redox stress.
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Affiliation(s)
- Anne Bertling
- Department of Anesthesiology, Intensive Care and Pain Medicine, Experimental and Clinical Hemostasis, University of Münster, Münster, Germany
| | - Martin F Brodde
- Department of Anesthesiology, Intensive Care and Pain Medicine, Experimental and Clinical Hemostasis, University of Münster, Münster, Germany.,OxProtect GmbH, Münster, Germany
| | - Mayken Visser
- Department of Anesthesiology, Intensive Care and Pain Medicine, Experimental and Clinical Hemostasis, University of Münster, Münster, Germany
| | - Janina Treffon
- Department of Anesthesiology, Intensive Care and Pain Medicine, Experimental and Clinical Hemostasis, University of Münster, Münster, Germany
| | - Michelle Fennen
- Department of Anesthesiology, Intensive Care and Pain Medicine, Experimental and Clinical Hemostasis, University of Münster, Münster, Germany
| | - Anke C Fender
- Institute of Pharmacology and Clinical Pharmacology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Reinhard Kelsch
- Institute of Transfusion Medicine and Transplantation Immunology, University Hospital Münster, Münster, Germany
| | - Beate E Kehrel
- Department of Anesthesiology, Intensive Care and Pain Medicine, Experimental and Clinical Hemostasis, University of Münster, Münster, Germany
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van Vulpen LFD, Popov-Celeketic J, van Meegeren MER, Coeleveld K, van Laar JM, Hack CE, Schutgens REG, Mastbergen SC, Lafeber FPJG. A fusion protein of interleukin-4 and interleukin-10 protects against blood-induced cartilage damage in vitro and in vivo. J Thromb Haemost 2017; 15:1788-1798. [PMID: 28696534 DOI: 10.1111/jth.13778] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Indexed: 12/30/2022]
Abstract
Essentials Targeted treatment for hemophilic arthropathy, still causing significant morbidity, is lacking. This study evaluates the efficacy of a fusion of protein of interleukin(IL)-4 and IL-10. In vitro the fusion protein prevents blood-induced cartilage damage in a dose-dependent manner. In hemophilic mice, the IL4-10 fusion protein ameliorates cartilage damage upon joint bleeding. SUMMARY Background Joint damage still causes significant morbidity in hemophilia. It results from synovial inflammation and direct cartilage-degenerating properties of blood components. Interleukin (IL)-4 and IL-10 have been shown to protect cartilage from blood-induced damage. Recently an IL4-10 fusion protein has been developed to combine the function of IL-4 and IL-10 and increase their bioavailability. Objectives In this study we evaluate whether this IL4-10 fusion protein protects against blood-induced joint damage. Methods In vitro, human cartilage explants were exposed to whole blood and simultaneously to a broad concentration range of the IL4-10 fusion protein. Effects on cartilage matrix turnover were compared with the individual cytokines. Moreover, the influence of the fusion protein and its individual components on IL-1β and IL-6 production was investigated. In hemophilia A mice, the effect of intra-articular treatment on synovitis and cartilage damage resulting from joint bleeding was evaluated by histochemistry. Results In vitro, the fusion protein prevented blood-induced cartilage damage in a dose-dependent manner, with equal effectiveness to the combination of the separate cytokines. In whole blood cultures 10 ng mL-1 fusion protein completely blocked the production of IL-1β and IL-6 by monocytes/macrophages. In hemophilic mice, intra-articular injection of IL-4 and IL-10 did not influence synovitis or cartilage degeneration. In contrast, equimolar amounts of the fusion protein attenuated cartilage damage upon repeated joint bleeding, although synovial inflammation was hardly affected. Conclusions Overall, this study shows that the IL4-10 fusion protein prevents blood-induced cartilage damage in vitro and ameliorates cartilage degeneration upon joint bleeding in hemophilic mice.
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Affiliation(s)
- L F D van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J Popov-Celeketic
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M E R van Meegeren
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - K Coeleveld
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C E Hack
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S C Mastbergen
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - F P J G Lafeber
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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van Vulpen LFD, Mastbergen SC, Lafeber FPJG, Schutgens REG. Differential effects of bleeds on the development of arthropathy - basic and applied issues. Haemophilia 2017; 23:521-527. [DOI: 10.1111/hae.13236] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 01/12/2023]
Affiliation(s)
- L. F. D. van Vulpen
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
- Department of Rheumatology & Clinical Immunology; University Medical Center Utrecht; Utrecht The Netherlands
| | - S. C. Mastbergen
- Department of Rheumatology & Clinical Immunology; University Medical Center Utrecht; Utrecht The Netherlands
| | - F. P. J. G. Lafeber
- Department of Rheumatology & Clinical Immunology; University Medical Center Utrecht; Utrecht The Netherlands
| | - R. E. G. Schutgens
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
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Pathophysiology of hemophilic arthropathy and potential targets for therapy. Pharmacol Res 2017; 115:192-199. [DOI: 10.1016/j.phrs.2016.11.032] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/04/2016] [Accepted: 11/23/2016] [Indexed: 01/14/2023]
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11
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The detrimental effects of iron on the joint: a comparison between haemochromatosis and haemophilia. J Clin Pathol 2015; 68:592-600. [DOI: 10.1136/jclinpath-2015-202967] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 03/29/2015] [Indexed: 12/21/2022]
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