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Piantoni S, Regola F, Angeli F, Caproli A, Trovati A, Tomasi C, Chiarini G, Rossini C, Rosei CA, De Ciuceis C, Franceschini F, Muiesan ML, Rizzoni D, Airò P. Retinal microvascular alterations in patients with active rheumatoid arthritis without cardiovascular risk factors: the potential effects of T cell co-stimulation blockade. Front Med (Lausanne) 2024; 11:1247024. [PMID: 38420362 PMCID: PMC10899475 DOI: 10.3389/fmed.2024.1247024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/05/2024] [Indexed: 03/02/2024] Open
Abstract
Background The evaluation of microvascular alterations might provide clinically useful information for patients with an increased cardiovascular (CV) risk, such as those with rheumatoid arthritis (RA), being the small artery remodeling the earliest form of target organ damage in primary CV diseases, such as arterial hypertension. The evaluation of retinal arterioles is a non-invasive technique aimed to identify an early microvascular damage, represented by the increase of the wall-to-lumen ratio (WLR) index. Abatacept (ABA), a T-cell co-stimulator blocker, is used to treat RA. A CV protective action was hypothesized for its peculiar mechanism of action in the modulation of T-cells, potentially involved in the pathogenesis of CV comorbidity. The study aimed to non-invasively investigate morphological characteristics of retinal arterioles in a cohort of RA patients treated with ABA. Materials and methods Seventeen RA patients [median (25th-75thpercentile) age = 58 (48-64) years, baseline 28-joint Disease Activity Score DAS28-C-reactive protein (DAS28-CRP) = 4.4 (3.9-4.6), body mass index (BMI) = 24.2 (23.4-26) kg/m2, rheumatoid factor positive:52.9%, anti-citrullinated peptide autoantibodies positive:76.5%] without known CV risk factors (arterial hypertension, diabetes, hypercholesterolemia, previous CV events, smoking) were evaluated by the adaptive optics imaging system of retinal arterioles before and every 6 months of therapy with ABA (T0, T6 and T12). Office blood pressure evaluation, 24-h ambulatory blood pressure monitoring and tissue-doppler echocardiography were also performed. Results A progressive significant reduction of the WLR of retinal arterioles was observed [T0 = 0.28 (0.25-0.30), T6 = 0.27 (0.24-0.31), T12 = 0.23 (0.23-0.26); p T0 vs. T6 = 0.414; p T6 vs. T12 = 0.02; p T0 vs. T12 = 0.009], without significant variations in other parameters. The T0-T12 reduction of WLR was correlated with that of DAS28-CRP (r:0.789; p = 0.005). Moreover, a significant reduction of diastolic office blood pressure and a trend for reduction of daily pressure measured by ambulatory monitoring were observed. Conclusion In a cohort of RA patients without known CV risk factors, a reduction of retinal microvascular alterations was demonstrated after treatment for 12 months with ABA, in parallel with the reduction of disease activity. These results might suggest the possibility of microvascular abnormalities regression induced by the immune system modulation.
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Affiliation(s)
- Silvia Piantoni
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesca Regola
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Fabrizio Angeli
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alessia Caproli
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Annalisa Trovati
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cesare Tomasi
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giulia Chiarini
- Internal Medicine Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudia Rossini
- Internal Medicine Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudia Agabiti Rosei
- Internal Medicine Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Carolina De Ciuceis
- Internal Medicine Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Lorenza Muiesan
- Internal Medicine Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Damiano Rizzoni
- Internal Medicine Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Airò
- Rheumatology and Clinical immunology Unit, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Xiao L, Yang Z, Lin S. Identification of hub genes and transcription factors in patients with rheumatoid arthritis complicated with atherosclerosis. Sci Rep 2022; 12:4677. [PMID: 35304503 PMCID: PMC8933589 DOI: 10.1038/s41598-022-08274-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/04/2022] [Indexed: 11/21/2022] Open
Abstract
The aim of this study was to explore the overlapping key genes, pathway networks and transcription factors (TFs) related to the pathogenesis of rheumatoid arthritis (RA) and atherosclerosis. The gene expression profiles of RA and atherosclerosis were downloaded from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) between RA and atherosclerosis were identified. The biological roles of common DEGs were explored through enrichment analysis. Hub genes were identified using protein–protein interaction networks. TFs were predicted using Transcriptional Regulatory Relationships Unraveled by Sentence Based Text Mining (TRRUST) database. The hub genes and TFs were validated with other datasets. The networks between TFs and hub genes were constructed by CytoScape software. A total of 131 DEGs (all upregulated) were identified. Functional enrichment analyses indicated that DEGs were mostly enriched in leukocyte migration, neutrophil activation, and phagocytosis. CytoScape demonstrated 12 hub genes and one gene cluster module. Four of the 12 hub genes (CSF1R, CD86, PTPRC, and CD53) were validated by other datasets. TRRUST predicted two TFs, including Spi-1 proto-oncogene (SPI1) and RUNX family transcription factor 1(RUNX1). The expression of RUNX1 was validated with another dataset. Our study explored the common pathogenesis of RA and atherosclerosis. These results may guide future experimental research and clinical transformation.
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Affiliation(s)
- Lu Xiao
- Department of Rheumatology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan, 570311, China
| | - Zhou Yang
- Department of Rheumatology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan, 570311, China
| | - Shudian Lin
- Department of Rheumatology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan, 570311, China.
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Rojas-Giménez M, López-Medina C, Calvo-Gutiérrez J, Puche-Larrubia MÁ, Gómez-García I, Seguí-Azpilcueta P, Ábalos-Aguilera MDC, Ruíz D, Collantes-Estévez E, Escudero-Contreras A. Association between Carotid Intima-Media Thickness and the Use of Biological or Small Molecule Therapies in Patients with Rheumatoid Arthritis. Diagnostics (Basel) 2021; 12:diagnostics12010064. [PMID: 35054229 PMCID: PMC8775122 DOI: 10.3390/diagnostics12010064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: The objective of this study was to assess the association of carotid intima-media thickness (CIMT), and also the presence of atheromatous plaque, with biological and targeted synthetic disease-modifying antirheumatic drugs, in an established cohort of patients with rheumatoid arthritis (RA). Patients and Methods: We conducted a cross-sectional observational study based on a cohort of patients with RA and a registry of healthy controls, in whom the CIMT and presence of atheromatous plaque were assessed by ultrasound. Data were collected on disease activity, lab results and treatments. Descriptive and bivariate analyses were performed and two multivariate linear regression models (with CIMT as the dependent variable) were constructed to identify variables independently associated with CIMT in our sample of patients with RA. Results: A total of 176 individuals (146 patients with RA and 30 controls) were included. A higher percentage of patients than controls had atheromatous plaque (33.8% vs. 12.5%, p = 0.036), but no differences were found in terms of CIMT (0.64 vs. 0.61, p = 0.444). Compared to values in patients on other therapies, the CIMT was smaller among patients on tumour necrosis factor alpha (TNFα) inhibitors (mean [SD]: 0.58 [0.10] vs. 0.65 [0.19]; p = 0.013) and among those on Janus kinase inhibitors (mean [SD]: 0.52 [0.02] vs. 0.64 [0.18]; p < 0.001), while no differences were found as a function of the use of the other therapies considered. The multivariate linear regression analysis to identify factors associated with CIMT in our patients, adjusting for traditional cardiovascular risk factors such as hypertension, high levels of low-density lipoproteins, diabetes mellitus and smoking, showed that male sex, older age and having a greater cumulative erythrocyte sedimentation rate were independently associated with a larger CIMT, while patients on TNFα inhibitors had a CIMT 0.075 mm smaller than those on other treatments. Conclusions: The use of TNFα inhibitors may protect against subclinical atherosclerosis in patients with RA, patients on this biologic having smaller CIMTs than patients on other disease-modifying antirheumatic drugs. Nonetheless, these results should be confirmed in prospective studies with larger sample sizes.
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Affiliation(s)
- Marta Rojas-Giménez
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Clementina López-Medina
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
- Correspondence:
| | - Jerusalem Calvo-Gutiérrez
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - María Ángeles Puche-Larrubia
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Ignacio Gómez-García
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Pedro Seguí-Azpilcueta
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
| | - María del Carmen Ábalos-Aguilera
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
| | - Desirée Ruíz
- Rheumatology Department, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research of Córdoba (IMIBIC), University of Córdoba (UCO), 14004 Cordoba, Spain; (M.R.-G.); (J.C.-G.); (M.Á.P.-L.); (I.G.-G.); (D.R.)
| | - Eduardo Collantes-Estévez
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
| | - Alejandro Escudero-Contreras
- Reina Sofia University Hospital, Maimonides Research Institute of Biomedical Medicine from Cordoba (IMIBIC), University of Córdoba, 14004 Cordoba, Spain; (P.S.-A.); (M.d.C.Á.-A.); (E.C.-E.); (A.E.-C.)
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Fragoulis GE, Soulaidopoulos S, Sfikakis PP, Dimitroulas T, D Kitas G. Effect of Biologics on Cardiovascular Inflammation: Mechanistic Insights and Risk Reduction. J Inflamm Res 2021; 14:1915-1931. [PMID: 34017189 PMCID: PMC8131071 DOI: 10.2147/jir.s282691] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
It is increasingly recognized that atherosclerosis and consequently cardiovascular disease (CVD) are closely linked with inflammatory processes. The latter is in the center of the pathogenic mechanism underlying autoimmune rheumatic diseases (ARD). It follows then, that optimal control of inflammation in ARDs may lead to a decrease of the accompanied CVD risk. Major trials (eg, CANTOS, CIRT), aimed at examining the possible benefits of immunomodulatory treatments in CVD, demonstrated conflicting results. On the other hand, substantial evidence is accumulating about the possible beneficial effects of biologic disease modifying antirheumatic drugs (bDMARDs) in patients with ARDs, particularly those with rheumatoid arthritis (RA). It seems that bDMARDs (some more than others) alter the lipid profile in RA patients but do not adversely affect, in most cases, the TC/HDL ratio. Favorable effects are noted for arterial stiffness and endothelial function. This is reflected in the lower risk for CVD events, seen in observational studies of RA patients treated with bDMARDs. It should be stressed that more data exist for the TNF-inhibitors than for other bDMARDs, such as tocilizumab, abatacept and rituximab. As regards the spondyloarthropathies (SpA), data are less robust. For TNF-inhibitors, effects appear to be on par with those seen in RA but no conclusions can be drawn for newer biologic drugs used in SpA (eg, IL-17 blockers). Finally, there is accumulating evidence for a beneficial effect of immunosuppressive treatment in cardiac inflammation and function in several ARDs. Introduction of newer therapeutic options in clinical practice seem to have a positive impact on CVD in the setting of ARD. This is probably due to better control of inflammation, but direct improvement in vascular pathology is also a valid hypothesis. Most data are derived from observational studies and, therefore, randomized controlled trials are needed to assess the possible favorable effect of bDMARDs on CVD outcomes.
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Affiliation(s)
- George E Fragoulis
- Rheumatology Unit, Joint Rheumatology Program, Medical School, First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, 115 27, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, 115 27, Greece
| | - Petros P Sfikakis
- Rheumatology Unit, Joint Rheumatology Program, Medical School, First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, 115 27, Greece
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, 546 41, Greece
| | - George D Kitas
- Department of Rheumatology, Russells Hall Hospital, Dudley Group NHS FT, Dudley, DY1 2HQ, UK.,Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, M13 9PT, UK
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Atzeni F, Rodríguez-Carrio J, Popa CD, Nurmohamed MT, Szűcs G, Szekanecz Z. Cardiovascular effects of approved drugs for rheumatoid arthritis. Nat Rev Rheumatol 2021; 17:270-290. [PMID: 33833437 DOI: 10.1038/s41584-021-00593-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
The risk of cardiovascular disease is increased in patients with rheumatoid arthritis compared with the general population owing to the influence of traditional and non-traditional risk factors. Inflammation has a pivotal contribution and can accelerate the atherosclerotic process. Although dampening inflammation with DMARDs should theoretically abrogate this process, evidence suggests that these drugs can also promote atherosclerosis directly and indirectly, hence adding to an increased cardiovascular burden. However, the extent and direction of the effects largely differ across drugs. Understanding how these drugs influence endothelial damage and vascular repair mechanisms is key to understanding these outcomes. NSAIDs and glucocorticoids can increase the cardiovascular risk. Conversely, conventional, biologic and targeted DMARDs control inflammation and reduce this risk, although some of these drugs can also aggravate traditional factors or thrombotic events. Given these data, the fundamental objective for clinicians should be disease control, in an individualized approach that considers the most appropriate drug for each patient, taking into account joint and cardiovascular outcomes. This Review provides a comprehensive analysis of the effects of DMARDs and other approved drugs on cardiovascular involvement in rheumatoid arthritis, from a clinical and mechanistic perspective, with a roadmap to inform the research agenda.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
| | - Javier Rodríguez-Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Călin D Popa
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, Nijmegen, The Netherlands
| | - Michael T Nurmohamed
- Deptartment of Rheumatology, Amsterdam University Medical Center & Reade, Amsterdam, The Netherlands
| | - Gabriella Szűcs
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Szekanecz
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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6
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Karpouzas GA, Bui VL, Ronda N, Hollan I, Ormseth SR. Biologics and atherosclerotic cardiovascular risk in rheumatoid arthritis: a review of evidence and mechanistic insights. Expert Rev Clin Immunol 2021; 17:355-374. [PMID: 33673792 DOI: 10.1080/1744666x.2021.1899809] [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] [Indexed: 12/23/2022]
Abstract
Introduction: Cardiovascular disease is a leading comorbidity in rheumatoid arthritis. Timely introduction of biologic therapies in a treat-to-target approach has optimized disease-related outcomes and attenuated accrual of comorbidities, including cardiovascular risk.Areas covered: A literature search in MEDLINE (via PubMed) was performed between January 2009 and November 2020. This manuscript explores recent developments in atherosclerotic cardiovascular risk in RA compared with non-RA individuals; it synopsizes differences in vascular function and inflammation, prevalence, burden, vulnerability, and progression of atherosclerotic plaque and their underlying cellular and molecular mechanisms. Finally, it reviews the recent literature on cardioprotective benefits of biologics and draws mechanistic links with inhibition of new plaque formation, stabilization of high-risk lesions and improvement in endothelial function, arterial stiffness, lipid metabolism, and traditional cardiac risk factors.Expert opinion: Increasing evidence points to a solid cardioprotective influence of earlier, longer, and ongoing use of biologic treatments in RA. Nevertheless, the precise mechanistic effects of plaque progression and remodeling, vascular stiffness, endothelial dysfunction, lipid metabolism, and traditional cardiac risk factors are less rigorously characterized.
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Affiliation(s)
- George A Karpouzas
- Division of Rheumatology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Viet L Bui
- Division of Rheumatology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nicoletta Ronda
- Department of Food and Drug, University of Parma, Parma, Italy
| | - Ivana Hollan
- The Norwegian University of Science and Technology, Gjøvik, Norway.,Beitostølen Sport and Health Centre, Beitostølen, Norway
| | - Sarah R Ormseth
- Division of Rheumatology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
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Fragoulis GE, Panayotidis I, Nikiphorou E. Cardiovascular Risk in Rheumatoid Arthritis and Mechanistic Links: From Pathophysiology to Treatment. Curr Vasc Pharmacol 2020; 18:431-446. [PMID: 31258091 DOI: 10.2174/1570161117666190619143842] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis (RA) is an autoimmune inflammatory arthritis. Inflammation, however, can spread beyond the joints to involve other organs. During the past few years, it has been well recognized that RA associates with increased risk for cardiovascular (CV) disease (CVD) compared with the general population. This seems to be due not only to the increased occurrence in RA of classical CVD risk factors and comorbidities like smoking, obesity, hypertension, diabetes, metabolic syndrome, and others but also to the inflammatory burden that RA itself carries. This is not unexpected given the strong links between inflammation and atherosclerosis and CVD. It has been shown that inflammatory cytokines which are present in abundance in RA play a significant role in every step of plaque formation and rupture. Most of the therapeutic regimes used in RA treatment seem to offer significant benefits to that end. However, more studies are needed to clarify the effect of these drugs on various parameters, including the lipid profile. Of note, although pharmacological intervention significantly helps reduce the inflammatory burden and therefore the CVD risk, control of the so-called classical risk factors is equally important. Herein, we review the current evidence for the underlying pathogenic mechanisms linking inflammation with CVD in the context of RA and reflect on the possible impact of treatments used in RA.
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Affiliation(s)
- George E Fragoulis
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Ismini Panayotidis
- Faculty of Medical Sciences, Medical School, University College London, London, United Kingdom
| | - Elena Nikiphorou
- Department of Inflammation Biology, King's College London, London, UK and Department of Rheumatology, King's College Hospital, London, United Kingdom
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