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Mohana-Borges AVR, Chung CB. Imaging of Rheumatic Diseases Affecting the Lower Limb. Rheum Dis Clin North Am 2024; 50:463-482. [PMID: 38942580 DOI: 10.1016/j.rdc.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Imaging methods capable of detecting inflammation, such as MR imaging and ultrasound, are of paramount importance in rheumatic disease management, not only for diagnostic purposes but also for monitoring disease activity and treatment response. However, more advanced stages of arthritis, characterized by findings of cumulative structural damage, have traditionally been accomplished by radiographs and computed tomography. The purpose of this review is to provide an overview of imaging of some of the most prevalent inflammatory rheumatic diseases affecting the lower limb (osteoarthritis, rheumatoid arthritis, and gout) and up-to-date recommendations regarding imaging diagnostic workup.
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Affiliation(s)
| | - Christine B Chung
- Department of Radiology, University of California San Diego, 9427 Health Sciences Drive, La Jolla, CA 92093, USA; Department of Radiology, VA San Diego, 3350 La Jolla Village Drive, La Jolla, CA 92161, USA.
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Karami P, Gholamin D, Fathi F, Afsar T, Johari-Ahar M. Anti-CCP biosensors in rheumatoid arthritis. Clin Chim Acta 2024; 561:119767. [PMID: 38857671 DOI: 10.1016/j.cca.2024.119767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
Biosensors are unique analytical tools for the detection of biomarkers. Of these, autoantibodies against citrullinated proteins (ACPA) are useful for the differential diagnosis of rheumatoid arthritis (RA). The autoantibodies may be detected by immunoassay technology using synthetic cyclic citrullinated peptides (CCP), ie, anti-CCP. Recently, several biosensors have been developed for anti-CCP using CCP and mutated citrullinated vimentin (MCV) as recognition elements. In this review we highlight all currently available ACPA biosensor technology including those based on fluorescence, chemiluminescence, electrochemiluminescence (ECL), surface-enhanced Raman scattering (SERS)-based, surface plasmon resonance (SPR), lateral flow immunoassays (LFIA), and electrochemical. We explore various peptides as recognition elements, electrode modifiers and signal amplification systems thus providing new opportunities for next-generation biosensor design in RA.
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Affiliation(s)
- Pari Karami
- Biosensor Sciences and Technologies Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Danial Gholamin
- Biosensor Sciences and Technologies Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Farzaneh Fathi
- Biosensor Sciences and Technologies Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Taha Afsar
- Biosensor Sciences and Technologies Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mohammad Johari-Ahar
- Biosensor Sciences and Technologies Research Center, Ardabil University of Medical Sciences, Ardabil, Iran; Department of Medicinal Chemistry and Pharmacognosy, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran.
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Dong R, Sun Y, Xu W, Xiang W, Li M, Yang Q, Zhu L, Ma Z. Distribution and clinical significance of anti-carbamylation protein antibodies in rheumatological diseases among the Chinese Han population. Front Immunol 2023; 14:1197458. [PMID: 37539050 PMCID: PMC10394697 DOI: 10.3389/fimmu.2023.1197458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
Objective Several studies have demonstrated that anti-carbamylation protein antibodies (Anti-CarPA) are persistent in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSC), primary Sjögren's syndrome (pSS), and interstitial lung disease associated with RA (RA-ILD). However, the relationship between anti-CarPA and other rheumatic diseases (RDs) and non-RA-ILD is not known till now. This study sought to examine the presence of anti-CarPA in Chinese Han patients with RDs and its clinical significance. Methods The study included 90 healthy controls (HCs) and 300 patients with RDs, including RA, SLE, polymyositis/dermatomyositis (PM/DM), pSS, SSC, spondyloarthritis (SpA), anti-neutrophil cytoplasmic autoantibodies associated with vasculitis (AAV), undifferentiated connective tissue disease (UCTD), and Behcet's disease (BD). Antibodies against carbamylated human serum albumin were detected using commercial enzyme-linked immunosorbent assay kits. Correlations between clinical and laboratory parameters were analyzed. Result Serum levels of anti-CarPA in RA (34.43 ± 33.34 ng/ml), SLE (21.12 ± 22.23 ng/ml), pSS (16.32 ± 13.54 ng/ml), PM/DM (30.85 ± 17.34 ng/ml), SSC (23.53 ± 10.70 ng/ml), and UCTD (28.35 ± 21.91 ng/ml) were higher than those of anti-CarPA in the HCs (7.30 ± 5.05 ng/ml). The concentration of serum anti-CarPA was higher in patients with rheumatic disease-related interstitial lung disease (RD-ILD), especially RA-ILD, PM/DM-ILD, and pSS-ILD. Patients with RD-ILD who tested positive for anti-CarPA were more likely to have a more severe radiographic classification (grades II, p = 0.045; grades III, p = 0.003). Binary logistic regression analysis suggested that anti-CarPA had an association with ILD in RA (p = 0.033), PM/DM (p = 0.039), and pSS (p = 0.048). Based on receiver operating characteristics (ROC) analysis, anti-CarPA cutoffs best discriminated ILD in RA (>32.59 ng/ml, p = 0.050), PM/DM (>23.46 ng/ml, p = 0.038), and pSS (>37.08 ng/ml, p = 0.040). Moreover, serum levels of anti-CarPA were correlated with antibodies against transcription intermediary factor 1 complex (anti-TIF1) (R = -0.28, p = 0.044), antibodies against glycyl-transfer ribonucleic acid synthetase (anti-EJ) (R = 0.30, p = 0.031), and antibodies against melanoma differentiation-associated gene 5 (anti-MDA5) (R = 0.35, p = 0.011). Conclusion Serum anti-CarPA could be detected in patients with RA, PM/DM, pSS, SSC, and UCTD among the Chinese Han population. And it may also assist in identifying ILD in patients with RA, PM/DM, and pSS, which emphasized attention to the lung involvement in anti-CarPA-positive patients.
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Affiliation(s)
- Rongrong Dong
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yuanyuan Sun
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Wei Xu
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Weizhen Xiang
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Meiqi Li
- Department of Rheumatology and Immunology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Qingrui Yang
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Rheumatology and Immunology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ling Zhu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhenzhen Ma
- Department of Rheumatology and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Rheumatology and Immunology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Radu AF, Bungau SG. Nanomedical approaches in the realm of rheumatoid arthritis. Ageing Res Rev 2023; 87:101927. [PMID: 37031724 DOI: 10.1016/j.arr.2023.101927] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
Rheumatoid arthritis (RA) is a heterogeneous autoimmune inflammatory disorder defined by the damage to the bone and cartilage in the synovium, which causes joint impairment and an increase in the mortality rate. It is associated with an incompletely elucidated pathophysiological mechanism. Even though disease-modifying antirheumatic drugs have contributed to recent improvements in the standard of care for RA, only a small fraction of patients is able to attain and maintain clinical remission without the necessity for ongoing immunosuppressive drugs. The evolution of tolerance over time as well as patients' inability to respond to currently available therapy can alter the overall management of RA. A significant increase in the research of RA nano therapies due to the possible improvements they may provide over traditional systemic treatments has been observed. New approaches to getting beyond the drawbacks of existing treatments are presented by advancements in the research of nanotherapeutic techniques, particularly drug delivery nano systems. Via passive or active targeting of systemic delivery, therapeutic drugs can be precisely transported to and concentrated in the affected sites. As a result, nanoscale drug delivery systems improve the solubility and bioavailability of certain drugs and reduce dose escalation. In the present paper, we provide a thorough overview of the possible biomedical applications of various nanostructures in the diagnostic and therapeutic management of RA, derived from the shortcomings of conventional therapies. Moreover, the paper suggests the need for improvement on the basis of research directions and properly designed clinical studies.
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Affiliation(s)
- Andrei-Flavius Radu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Simona Gabriela Bungau
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania.
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Imaging of Rheumatic Diseases Affecting the Lower Limb. Radiol Clin North Am 2023; 61:345-360. [PMID: 36739149 DOI: 10.1016/j.rcl.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Imaging methods capable of detecting inflammation, such as MR imaging and ultrasound, are of paramount importance in rheumatic disease management, not only for diagnostic purposes but also for monitoring disease activity and treatment response. However, more advanced stages of arthritis, characterized by findings of cumulative structural damage, have traditionally been accomplished by radiographs and computed tomography. The purpose of this review is to provide an overview of imaging of some of the most prevalent inflammatory rheumatic diseases affecting the lower limb (osteoarthritis, rheumatoid arthritis, and gout) and up-to-date recommendations regarding imaging diagnostic workup.
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Haj‐Mirzaian A, Kubassova O, Boesen M, Carrino J, Bird P. Computer‐Assisted Image Analysis in Assessment of Peripheral Joint
MRI
in Inflammatory Arthritis: A Systematic Review and Meta‐analysis. ACR Open Rheumatol 2022; 4:721-734. [PMID: 35689340 PMCID: PMC9374055 DOI: 10.1002/acr2.11450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/29/2022] [Accepted: 04/15/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To summarize the feasibility of computer‐assisted quantification of joint pathologies on magnetic resonance imaging (MRI) in patients with inflammatory arthritis by evaluating the published data on reliability, validity, and feasibility. Methods A systematic literature search was performed for original articles published from January 1, 1985, to January 1, 2021. We selected studies in which patients with inflammatory arthritis were enrolled, and arthritis‐related structural damage/synovitis in peripheral joints was assessed on non‐contrast‐enhanced, contrast‐enhanced (CE), or dynamic CE (DCE)‐MRI using (semi)automated methods. Data were pooled using random‐effects model. Results Twenty‐eight studies consisting of 1342 MRIs were included (mean age, 54.8 years; 66.7% female; duration of arthritis, 3.6 years). Among clinical/laboratory factors, synovial membrane volume (SV) was moderately correlated with erthrocyte sedimentation rate (ESR) level (P < 0.01). Pooled analysis showed an overall excellent intra‐ and inter‐reader reliability for computer‐aided quantification of bone erosion volume (BEV; r = 0.97 [95% CI: 0.92‐0.99], 0.93 [0.87‐0.97]), SV (r = 0.98 [95% CI: 0.90‐0.99], 0.86 [0.78‐0.91]), and DCE‐MRI perfusion parameters (r = 0.96‐0.99). Meta‐regression showed that computer‐aided and manual methods provide comparable reliability (P > 0.05). Computer‐aided measurement of BEV (r = 0.92), SV (r = 0.82), and DCE‐MRI biomarkers (r = 0.72 N‐total; r = 0.74 N‐plateau; r = 0.64 N‐washout) were significantly correlated with the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS; P < 0.01), allowing for earlier assessment of drug efficacy. On average, (semi)automated analysis of BEV/SV took 17 minutes (vs. 9 minutes for the RAMRIS) and DCE‐MRI took 4 minutes (vs. 33 minutes for manual assessment). Conclusion Computer‐aided image quantification technologies demonstrate excellent reliability and validity when used to quantify MRI pathologies of peripheral joints in patients with inflammatory arthritis. Computer‐aided evaluation of inflammatory arthritis is an emerging field and should be considered as a viable complement to conventional observer‐based scoring methods for clinical trials application.
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Affiliation(s)
| | | | - Mikael Boesen
- University Hospital Bispebjerg and Frederiksberg; The Parker Institute Copenhagen Denmark
| | - John Carrino
- Hospital for Special Surgery Hackensack New Jersey
| | - Paul Bird
- University of New South Wales Sydney New South Wales Australia
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Radu AF, Bungau SG. Management of Rheumatoid Arthritis: An Overview. Cells 2021; 10:2857. [PMID: 34831081 PMCID: PMC8616326 DOI: 10.3390/cells10112857] [Citation(s) in RCA: 238] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/16/2021] [Accepted: 10/22/2021] [Indexed: 02/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a multifactorial autoimmune disease of unknown etiology, primarily affecting the joints, then extra-articular manifestations can occur. Due to its complexity, which is based on an incompletely elucidated pathophysiological mechanism, good RA management requires a multidisciplinary approach. The clinical status of RA patients has improved in recent years due to medical advances in diagnosis and treatment, that have made it possible to reduce disease activity and prevent systemic complications. The most promising results were obtained by developing disease-modifying anti-rheumatic drugs (DMARDs), the class to which conventional synthetic, biologic, and targeted synthetic drugs belong. Furthermore, ongoing drug development has led to obtaining molecules with improved efficacy and safety profiles, but further research is needed until RA turns into a curable pathology. In the present work, we offer a comprehensive perspective on the management of RA, by centralizing the existing data provided by significant literature, emphasizing the importance of an early and accurate diagnosis associated with optimal personalized treatment in order to achieve better outcomes for RA patients. In addition, this study suggests future research perspectives in the treatment of RA that could lead to higher efficacy and safety profiles and lower financial costs.
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Affiliation(s)
- Andrei-Flavius Radu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
| | - Simona Gabriela Bungau
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
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ITGA2 protein is associated with rheumatoid arthritis in Chinese and affects cellular function of T cells. Clin Chim Acta 2021; 523:208-215. [PMID: 34599900 DOI: 10.1016/j.cca.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND We identified proteins significant for rheumatoid arthritis (RA) in peripheral blood mononuclear cells (PBMCs), and to clarify mechanisms mediated by underlying proteins that may involve in the pathogenesis of RA. METHODS Proteome-wide protein expressions were profiled by employing label-free quantitative proteomics methodology (Easy-nLC1000 and Q-exactive). The t-test was applied to identify differentially expressed proteins (DEP, p ≤ 0.05) between RA case and control samples. Gene Ontology enrichment analyses and Protein-Protein Interaction analyses were performed to annotate functions of DEPs. The selected DEP was validated in independent samples using Simple Western assay. Plasma protein level of α2 component of integrin (ITGA2) was measured by using ELISA. The DEP, ITGA2, was assessed for its effects on T cell proliferation, cell cycle, apoptosis, and inflammatory cytokine expression. RESULTS Sixty-four DEPs (p < 0.05) were identified in PBMCs. The selected ITGA2 (Fold Change, FC = 2.20, p = 1.49E-02) was validated to be up-regulated (FC = 12.33, p = 4.90E-2) with RA, and plasma ITGA2 protein level significantly elevated in RA patients vs. controls. Over-expression of ITGA2 could promote proliferation and inhibit apoptosis of Jurkat T cell, and induce IL-8, IFN-γ and TNF-α expression in Jurkat T cells. CONCLUSIONS ITGA2 protein was significantly over-expressed in PBMCs in RA patients, and affects T cell growth and pro-inflammatory cytokine expression in T cells.
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Alexandre DJA, Carmo CCM, Romeiro LD, Gutfilen-Schlesinger G, Amarante JLM, de Souza SAL, Gutfilen B. 99mTc-antitumor necrosis factor-alpha scintigraphy for the detection of inflammatory activity in rheumatoid arthritis. Nucl Med Commun 2021; 42:389-395. [PMID: 33306625 DOI: 10.1097/mnm.0000000000001333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tumor necrosis factor-alpha (TNF-α) is an important inflammatory cytokine. 99mTc-anti-TNF-α antibody scintigraphy has proven to be a viable alternative to MRI in specific cases. The objective of this study was to evaluate the performance of scintigraphy with 99mTc-anti-TNF-α in the identification of inflammatory foci in individuals diagnosed with rheumatoid arthritis using MRI as the gold standard. METHODS This cross-sectional, descriptive and analytical-qualitative clinical study compared the performance of 99mTc-anti-TNF-α scintigraphy with that of MRI with intravenous administration of gadolinium (used as the gold standard) and a clinical examination (Disease Activity Score 28) in 220 joints of 20 patients with a diagnosis of rheumatoid arthritis and one healthy control. RESULTS The concordance of scintigraphy with MRI in individuals with a diagnosis of rheumatoid arthritis was 79%. The accuracy, sensitivity and specificity of scintigraphy for distinguishing between inflammatory and noninflammatory sites were 92, 89, and 93%, respectively. No adverse reactions to the examinations were reported. CONCLUSIONS Scintigraphy with 99mTc-anti-TNF-α was well-tolerated and had a good ability to distinguish between inflammatory and noninflammatory lesions in patients with rheumatoid arthritis.
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Affiliation(s)
- Dângelo J A Alexandre
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro
- Physical Therapy Service, National Institute of Traumatology and Orthopedics
| | - Clarissa C M Carmo
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro
| | - Leonardo D Romeiro
- Rheumatology Service, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
| | | | - José L M Amarante
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro
| | - Sergio A L de Souza
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro
| | - Bianca Gutfilen
- Department of Radiology, School of Medicine, Federal University of Rio de Janeiro
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竺 红, 赵 丽, 周 艳, 陈 瑶. [Significance of anti-carbamylated protein antibodies in patients with rheumatoid arthritis-associated intersitial lung disease]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:1003-1007. [PMID: 31848494 PMCID: PMC7433599 DOI: 10.19723/j.issn.1671-167x.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the value of anti-carbamylated protein (CarP) antibody in the diagnosis of rheumatoid arthritis-associated intersitial lung diseas (RA-ILD). METHODS Clinical and laboratory data and serum samples of patients with RA between December 2017 and June 2019 in Department of Rheumatology, General Hospital of Ningxia Medical University were collected. The patients were subclassified as RA-ILD and RA-without ILD based on computed tomography scans of the chest, Enzyme 1inked immunosorbent assay (ELISA) was used to assess anti-CarP antibody in the serum of each group. The occurrence of ILD and other laboratory indexes were analyzed. Comparison of measurement data between the 2 groups was performed by two independent sample t-test or Mann-Whitney U nonparametric test, while the count data were compared by Chi square test; Receiver operating characteristic curve (ROC) was drawn to determine the cut-off value of anti-CarP antibody to RA-ILD diagnosis and to analyze its diagnostic efficacy. RESULTS The anti-CarP antibody level in the RA-ILD group was 21.14 (12.29, 29.75), which was significantly higher than that in the RA-without ILD group 11.6 (6.66, 19.05) (P=0.000). The difference was statistically significant (P<0.05). The positive rate of anti-CarP antibody in RA-ILD group (53%) was significantly higher than that in RA-without ILD group (16%) (P<0.05); There was no significant differences in the levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) between the two groups (P>0.05). The age and disease activity score (DAS28) in the RA-ILD group were significantly higher than those in the RA-withhout ILD group (P<0.05). The proportion of men and smoking in the RA-ILD group was higher than that in the RA-without ILD group, but the difference was not statistically significant. The ROC curve showed that the anti-CarP antibody had a cut off value of 20.56 U/mL, with the sensitivity of 53.50%, and specificity of 84.20%, the area under the ROC curve were 0.76. Spearman correlation analysis showed that rheumatoid factor (RF) and age were positively correlated with anti-CarP antibody (r=0.172, P=0.043; r=0.200, P=0.006). Anti-CarP antibody level was not associated with the DAS28 score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-CCP antibody, swollen joint count, and tender joint count (P>0.05). CONCLUSION The anti-CarP antibody level in RA-ILD patients is higher than that in RA-without ILD, suggesting that anti-CarP antibody may have a role in the development of RA-ILD.
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Affiliation(s)
- 红 竺
- 宁夏医科大学总医院风湿免疫科,宁夏银川 750004Department of Rheumatology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - 丽娟 赵
- 宁夏医科大学临床医学院,宁夏银川 750004Department of Clinical Medical College, Ningxia Medical University, Yinchuan, 750004, China
| | - 艳 周
- 宁夏医科大学总医院风湿免疫科,宁夏银川 750004Department of Rheumatology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - 瑶 陈
- 宁夏医科大学临床医学院,宁夏银川 750004Department of Clinical Medical College, Ningxia Medical University, Yinchuan, 750004, China
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MMP3 is a reliable marker for disease activity, radiological monitoring, disease outcome predictability, and therapeutic response in rheumatoid arthritis. Best Pract Res Clin Rheumatol 2019; 32:550-562. [PMID: 31174824 DOI: 10.1016/j.berh.2019.01.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Matrix metalloproteinase-3 or MMP3 also known as stromelysin-1 is an enzyme that is actively involved in joint destruction in rheumatoid arthritis (RA) patients. Screening the last three decades, it appears that serum levels of MMP3 reflect positively RA disease activity, joint and bone injury, and radiological erosion and predict disease outcome and drug responsiveness as summarized in several publications reporting outcomes on more than 8000 patients with RA. MMP-3 monitoring should be embedded in the routine assessment and accompany therapeutic modalities, in personalized medical RA management.
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Kgoebane K, Ally MMTM, Duim-Beytell MC, Suleman FE. The role of imaging in rheumatoid arthritis. SA J Radiol 2018; 22:1316. [PMID: 31754498 PMCID: PMC6837821 DOI: 10.4102/sajr.v22i1.1316] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/29/2018] [Indexed: 12/02/2022] Open
Abstract
Conventional radiographs of the hands and feet have traditionally been used in the diagnosis, management and monitoring of patients with rheumatoid arthritis (RA). However, they are not sensitive enough to detect changes early in the disease process. Erosions may only be visible up to two years after the onset of disease, and soft tissue involvement may not be detected at all. Early diagnosis can also be made challenging as markers such as erythrocyte sedimentation rate and C-reactive protein may be normal in up to 20% - 25% of cases. The latest classification criteria (American College of Rheumatology/European League Against Rheumatism [ACR/EULAR] Rheumatoid Arthritis Classification criteria 2010), often used to diagnose RA, incorporate the role of ultrasound and magnetic resonance imaging detection of synovitis, enabling earlier diagnosis and correct classification of patients. This article looks at the role of the various imaging modalities used in the diagnosis and management of RA.
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Othman MA, Ghazali WSW, Hamid WZWA, Wong KK, Yahya NK. Anti-carbamylated protein antibodies in rheumatoid arthritis patients and their association with rheumatoid factor. Saudi Med J 2018; 38:934-941. [PMID: 28889152 PMCID: PMC5654028 DOI: 10.15537/smj.2017.9.20841] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To evaluate levels of anti-carbamylated protein (anti-CarP) antibodies in rheumatoid arthritis (RA) patients and to determine their association with serological parameters and disease activity. Methods: A cross-sectional study involving 105 multiethnic RA patients (48 rheumatoid factor [RF]-positive and 57 RF-negative patients) was conducted at Hospital Universiti Sains Malaysia, Kelantan, Malaysia, from January 2015 to February 2016. Fifty healthy controls (HCs) were included. C-reactive protein (CRP), RF, anti-cyclic citrullinated peptide (anti-CCP) and anti-CarP antibodies were measured. A health assessment questionnaire (HAQ) was administered to the study participants and 28-joint Disease Activity Score (DAS28) were obtained. Results: The level of anti-CarP antibodies was significantly increased in the RA patients compared with HCs (p=0.042). The presence of anti-CarP antibodies was significantly associated with RF (p=0.019) and the HAQ (p=0.010). A significant association between the presence of anti-CarP antibodies and the DAS28 was not found (p=0.632). Conclusion: Our study provides further evidence that the level of anti-CarP antibodies is significantly elevated in RA patients.
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Affiliation(s)
- Maizatul A Othman
- Department of Immunology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia. E-mail.
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Bakir E, Baglama SS, Gursoy S. The effects of reflexology on pain and sleep deprivation in patients with rheumatoid arthritis: A randomized controlled trial. Complement Ther Clin Pract 2018; 31:315-319. [DOI: 10.1016/j.ctcp.2018.02.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/09/2018] [Accepted: 02/28/2018] [Indexed: 12/18/2022]
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15
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Khojah HM, Ahmed S, Abdel-Rahman MS, Alkhalil KM, Hamza AB. Vitamin K homologs as potential biomarkers for disease activity in patients with rheumatoid arthritis. J Bone Miner Metab 2017; 35:529-535. [PMID: 27722902 DOI: 10.1007/s00774-016-0785-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/05/2016] [Indexed: 01/16/2023]
Abstract
The aim of this study was to evaluate the possible role of vitamin K homologs as potential biomarkers for disease activity in patients with rheumatoid arthritis (RA). In this study, 42 patients with RA and 40 healthy controls were enrolled. Serum levels of vitamin K homologs were measured using a high-performance liquid chromatography-fluorescence method. Different biochemical and clinical markers for disease activity were measured and correlated with serum levels of vitamin K homologs. There were no significant differences between RA patients and healthy subjects in demographic data. Patients with RA showed significantly higher levels of biochemical markers compared with healthy subjects (p < 0.001). These markers included rheumatoid factor (RF), anticyclic citrullinated polypeptide (anti-CCP), undercarboxylated osteocalcin (ucOC), matrix metalloproteinase (MMP-3), C-reactive protein (CRP), and disease activity score assessing 28 joints with erythrocyte sedimentation rate (DAS28-ESR). In addition, serum levels of vitamin K homologs were reduced in RA patients, and the levels of menaquinone-4 (MK-4) and menaquinone-7 (MK-7) were moderately to strongly inversely correlated with the clinical articular features in RA patients, whereas phylloquinone (PK) levels were weakly correlated. Serum levels of MK-4, MK-7 and PK were strongly inversely correlated with ucOC, MMP-3 and DAS28-ESR in RA patients. In contrast, serum levels of MK-4, MK-7 and PK were weakly correlated with CRP, RF and anti-CCP. These results suggest that serum levels of vitamin K homologs may be considered as potential biomarkers for disease activity. In addition, the results confirm the role of vitamin K deficiency in the etiology of RA.
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Affiliation(s)
- Hani M Khojah
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, Saudi Arabia.
| | - Sameh Ahmed
- Department of Pharmacognosy and Pharmaceutical Chemistry, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, Saudi Arabia
| | - Mahran S Abdel-Rahman
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, Saudi Arabia
- Department of Pharmacology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khaled M Alkhalil
- Department of Rheumatology, King Fahd Hospital, Al Madinah AlMunawarah, Saudi Arabia
| | - Al-Badr Hamza
- Department of Rheumatology, King Fahd Hospital, Al Madinah AlMunawarah, Saudi Arabia
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Elsayed HMA, Khater WS, Ibrahim AA, Hamdy MSED, Morshedy NA. MicroRNA-146a expression as a potential biomarker for rheumatoid arthritis in Egypt. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2017. [DOI: 10.1016/j.ejmhg.2016.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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17
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Othman MA, Ghazali WSW, Yahya NK, Wong KK. Correlation of Demographic and Clinical Characteristics with Rheumatoid Factor Seropositivity in Rheumatoid Arthritis Patients. Malays J Med Sci 2016; 23:52-59. [PMID: 28090179 PMCID: PMC5181992 DOI: 10.21315/mjms2016.23.6.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/02/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The rheumatoid factor (RF) blood test is the most commonly adopted test for the diagnosis of rheumatoid arthritis (RA). RA patients who are seropositive for RF might face a greater likelihood of developing more aggressive symptoms. METHODS Our goal was to study the demographic and clinical characteristics, as well as their correlation with RF seropositivity, among a series of 80 RA patients aged ≥ 18 years who attend Hospital Universiti Sains Malaysia (HUSM). RESULTS Of the 80 RA patients included in this study, 66 (82.5%) were female and 14 (17.5%) were male. No significant associations between RF seropositivity and demographic and/or clinical characteristics or other laboratory investigations were observed, including gender, morning stiffness, individual joint involvement (from multiple sites of the body), and erythrocyte sedimentation rate (ESR) measurement. However, a significant association between RF seropositivity and patients aged ≥ 50 was found (P = 0.032). CONCLUSION RF seropositivity was found to be more common in much older RA patients.
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Affiliation(s)
- Maizatul Akmal Othman
- Department of Immunology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Syamimee Wan Ghazali
- Department of Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Nurul Khaiza Yahya
- Department of Immunology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Kah Keng Wong
- Department of Immunology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Khojah HM, Ahmed S, Abdel-Rahman MS, Hamza AB. Reactive oxygen and nitrogen species in patients with rheumatoid arthritis as potential biomarkers for disease activity and the role of antioxidants. Free Radic Biol Med 2016; 97:285-291. [PMID: 27344969 DOI: 10.1016/j.freeradbiomed.2016.06.020] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/16/2016] [Accepted: 06/19/2016] [Indexed: 01/16/2023]
Abstract
Reactive oxygen species (ROS) and reactive nitrogen species (RNS) have distinct contribution to the destructive, proliferative synovitis of rheumatoid arthritis (RA) and play a prominent role in cell-signaling events. However, few studies had clarified the role of individual ROS and RNS in the etiopathogenesis of RA. To date, most of the studies were concerned with the measurement of the total oxidative and nitrative stress levels in RA. The aim of this study was to monitor the levels of individual ROS and RNS to emphasize the role that each plays in the pathogenesis of RA and their usefulness as possible biomarkers for the disease activity. In addition, the effect of an antioxidant (ascorbic acid), added to the treatment regimen, on the levels of ROS, RNS and disease activity has been evaluated. Forty-two Saudi RA patients and 40 healthy controls of both genders were included in this study. Serum levels of six different ROS and three different RNS were measured using specific fluorescent probes. The ROS included the hydroxyl radical ((•)OH), the superoxide anion (O2(•-)), hydrogen peroxide (H2O2), the singlet oxygen ((1)O2), the hypochlorite radical (OHCl(•)), and the peroxyl radical (ROO(•)). The RNS included nitric oxide (NO(•)), nitrogen dioxide (ONO-) and peroxynitrite (ONOO-). The main clinical and biochemical markers for disease activity were assessed and correlated with ROS and RNS levels. The clinical markers included the 28 swollen joint count (SJC-28), the 28-tender joint count (TJC-28), morning stiffness and symmetric arthritis, in addition to the disease activity score assessing 28 joints with erythrocyte sedimentation rate (DAS28-ESR). The biochemical markers included undercarboxylated osteocalcin (ucOC), matrix metalloproteinase (MMP-3), ESR, C-reactive protein (CRP), rheumatoid factor (RF) and anticyclic citrullinated polypeptide (Anti-CCP). Ascorbic acid (1mg/day) was added as an antioxidant to the regular treatment regimen of RA patients for two months, and the levels of ROS and RNS, as well as disease activity were re-evaluated. The results have shown significant higher serum levels of individual ROS and RNS in RA patients compared with healthy subjects. Moreover, this study might be the first to report strong positive correlations between most of the reactive species and the clinical and biochemical markers of RA. Interestingly, the addition of ascorbic acid had significantly reduced the levels of all ROS and RNS in RA patients. In conclusion, the role of oxidative and nitrative stress in the pathogenesis of RA has been confirmed by this study. Serum levels of ROS and RNS may effectively serve as biomarkers for monitoring disease progression. Finally, the addition of an antioxidant, such as ascorbic acid, in the management of RA may be of a great value.
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Affiliation(s)
- Hani M Khojah
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, Saudi Arabia.
| | - Sameh Ahmed
- Department of Pharmacognosy and Pharmaceutical Chemistry, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, Saudi Arabia
| | - Mahran S Abdel-Rahman
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Al Madinah AlMunawarah, Saudi Arabia; Department of Pharmacology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Al-Badr Hamza
- King Fahd Hospital, Al Madinah AlMunawarah, Saudi Arabia
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Li L, Deng C, Chen S, Zhang S, Wu Z, Hu C, Zhang F, Li Y. Meta-Analysis: Diagnostic Accuracy of Anti-Carbamylated Protein Antibody for Rheumatoid Arthritis. PLoS One 2016; 11:e0159000. [PMID: 27437936 PMCID: PMC4954701 DOI: 10.1371/journal.pone.0159000] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/24/2016] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE The anti-carbamylated protein (CarP) antibody is a novel biomarker that might help in the diagnosis of rheumatoid arthritis (RA). We aim to assess the diagnostic value of anti-CarP antibody for RA. METHODS We systematically searched PubMed, Embase, the Cochrane Library, Web of Science, and Scopus for studies published by December 15, 2015. Studies in any language that evaluated the utility of the anti-CarP antibody in the diagnosis of RA in which healthy donors or patients without arthritis or arthralgia served as controls were included. Two investigators independently evaluated studies for inclusion, assessed study quality and abstracted data. A bivariate mixed-effects model was used to summarize the diagnostic indexes from 7 eligible studies. RESULTS The pooled sensitivity, specificity, and positive and negative likelihood ratios for anti-CarP antibody were 42% (95% CI, 38% to 45%), 96% (95% CI, 95% to 97%), 10.2 (95% CI, 7.5 to 13.9), and 0.61 (95% CI, 0.57 to 0.65), respectively. The summary diagnostic odds ratio was 17 (95% CI, 12 to 24), and the area under summary receiver operator characteristic curve was 80% (95% CI, 77% to 84%). CONCLUSION Anti-CarP antibody has a moderate value in the diagnosis of RA with high specificity but relatively low sensitivity.
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Affiliation(s)
- Liubing Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chuiwen Deng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Si Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shulan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ziyan Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chaojun Hu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yongzhe Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Wyseure T, Mosnier LO, von Drygalski A. Advances and challenges in hemophilic arthropathy. Semin Hematol 2015; 53:10-9. [PMID: 26805902 DOI: 10.1053/j.seminhematol.2015.10.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 12/13/2022]
Abstract
Hemophilic arthropathy is a form of joint disease that develops secondary to joint bleeding and presents with synovial hypertrophy, cartilage and bony destruction. The arthropathy can develop despite clotting factor replacement and is especially disabling in the aging population. Pathobiological tissue changes are triggered by release of hemoglobin and iron deposition in the joint, but the sequence of events and the molecular mechanisms resulting in joint deterioration are incompletely understood. Treatment options other than clotting factor replacement are limited. Improvements in the treatment of hemophilia necessitate a better understanding of the processes that lead to this disabling condition and better diagnostic tools. Towards that end, studies of the molecular mechanisms leading to the arthropathy, as well as the development of sensitive imaging techniques and biomarkers are needed. These will pave the way to identify the cause of acute pain such as joint bleeding or synovitis, detect early, potentially reversible structural changes, and predict progression of disease. This review describes current imaging techniques and the development of high resolution musculoskeletal ultrasound with power Doppler to afford point-of-care diagnosis and management, the potential utility of diagnostic biomarkers, and summarizes our current knowledge of the pathobiology of hemophilic arthropathy.
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Affiliation(s)
- Tine Wyseure
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Laurent O Mosnier
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA
| | - Annette von Drygalski
- The Scripps Research Institute, Department of Molecular and Experimental Medicine, La Jolla, CA, USA; University of California at San Diego, Department of Medicine, San Diego, CA, USA.
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Grassi W, Okano T, Di Geso L, Filippucci E. Imaging in rheumatoid arthritis: options, uses and optimization. Expert Rev Clin Immunol 2015; 11:1131-46. [DOI: 10.1586/1744666x.2015.1075395] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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22
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Selmi C, Shoenfeld Y. Open questions in autoimmunity: discussions from the 2013 Controversies in Rheumatology and Autoimmunity Meeting. BMC Med 2014; 12:50. [PMID: 24642104 PMCID: PMC3984700 DOI: 10.1186/1741-7015-12-50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/07/2014] [Indexed: 12/14/2022] Open
Abstract
The recent CORA (Controversies in Rheumatology and Autoimmunity) meeting held in 2013 represented a unique opportunity for rheumatologists to address several topics. Among these, four topics include: (i) the role of epigenetic changes in the pathogenesis of rheumatoid arthritis (RA), as shown by studies in monozygotic twins; (ii) the cardiovascular and atherosclerotic risk in patients with RA treated with biologics; (iii) the use of new biomarkers for the diagnosis and follow-up of RA and other autoimmune diseases, as represented by the new automatic machines for anti-nuclear antibodies detection, or ultrasound imaging to follow RA progression; and (iv) the latest guidelines on how to use and manage biologic therapies in RA and other autoimmune diseases, such as lupus. In summary, we will herein present these topics of discussion and underline the conclusions obtained by rheumatologists during the 2013 CORA Meeting.
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Affiliation(s)
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer 52621, Israel Incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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