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Popova V, Geneva-Popova M, Popova-Belova S, Doykov M, Valkanov S, Batalov Z, Marinkov A, Karalilova R. Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis. Rheumatol Int 2024; 44:1295-1303. [PMID: 38554194 DOI: 10.1007/s00296-024-05568-7] [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: 02/04/2024] [Accepted: 02/23/2024] [Indexed: 04/01/2024]
Abstract
ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.
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Affiliation(s)
- Velichka Popova
- Department of Rheumatology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria.
| | - Mariela Geneva-Popova
- Department of Rheumatology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | | | - Mladen Doykov
- Department of Urology and General Medicine, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Stanislav Valkanov
- Department of Urology and General Medicine, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Zguro Batalov
- Department of Rheumatology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Aleksandar Marinkov
- Department of Rheumatology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Rositsa Karalilova
- Department of Rheumatology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
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Zou X, Huo F, Sun L, Huang J. Peripheral helper T cells in human diseases. J Autoimmun 2024; 145:103218. [PMID: 38574420 DOI: 10.1016/j.jaut.2024.103218] [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: 01/22/2024] [Revised: 03/04/2024] [Accepted: 03/29/2024] [Indexed: 04/06/2024]
Abstract
Peripheral helper T cells (Tph) are a specialized subset of CD4+ T cells with the ability to help B cells and induce antibody production. Although usually located in ectopic lymphoid-like structures (ELS), inside the peripheral blood, Tph cells can also be identified. The aberrant proliferation and functions of Tph cells are commonly found in the patients with disease. In this review, first we will summarize the biological characteristics of Tph cells, such as the expression of surface molecules, transcription factors and cytokines, and discuss its B cell help functions. Tph cells also have roles in a wide range of human diseases, including autoimmune diseases, infectious diseases, malignancies etc. Therefore, there is a strong interest in targeting Tph cells to improve treat strategies of human diseases.
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Affiliation(s)
- Xueyang Zou
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, 130000, PR China
| | - Feifei Huo
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130000, PR China
| | - Lulu Sun
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, 130000, PR China
| | - Jing Huang
- Department of Clinical Laboratory, The First Hospital of Jilin University, Changchun, 130000, PR China.
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Shumnalieva R, Ermencheva P, Kotov G, Parvova-Hristova I, Bakopoulou K, Kaouri IE, Mileva N, Velikova T. New Biomarkers for Systemic Necrotizing Vasculitides. J Clin Med 2024; 13:2264. [PMID: 38673537 PMCID: PMC11050764 DOI: 10.3390/jcm13082264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/29/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Systemic necrotising vasculitides (SNVs) pose significant challenges due to their diverse clinical manifestations and variable outcomes. Therefore, identifying reliable biomarkers holds promise for improving precision medicine in SNVs. This review explores emerging biomarkers aiming to enhance diagnostic accuracy, prognostic assessment, and disease monitoring. We discuss recent advances in immunological biomarkers, inflammatory indicators, and other parameters that exhibit potential diagnostic and prognostic utility. A comprehensive understanding of these biomarkers may facilitate earlier and more accurate SNV detection, aiding in timely intervention and personalized treatment strategies. Furthermore, we highlight the evolving landscape of disease monitoring through innovative biomarkers, shedding light on their dynamic roles in reflecting disease activity and treatment response. Integrating these novel biomarkers into clinical practice can revolutionize the management of SNVs, ultimately improving patient outcomes and quality of life.
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Affiliation(s)
- Russka Shumnalieva
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical University of Sofia, 13 Urvich St., 1612 Sofia, Bulgaria; (R.S.); (P.E.); (G.K.); (I.P.-H.)
- Medical Faculty, Sofia University, St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria;
| | - Plamena Ermencheva
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical University of Sofia, 13 Urvich St., 1612 Sofia, Bulgaria; (R.S.); (P.E.); (G.K.); (I.P.-H.)
| | - Georgi Kotov
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical University of Sofia, 13 Urvich St., 1612 Sofia, Bulgaria; (R.S.); (P.E.); (G.K.); (I.P.-H.)
| | - Iva Parvova-Hristova
- Department of Rheumatology, Clinic of Rheumatology, University Hospital St. Ivan Rilski, Medical University of Sofia, 13 Urvich St., 1612 Sofia, Bulgaria; (R.S.); (P.E.); (G.K.); (I.P.-H.)
| | - Konstantina Bakopoulou
- Faculty of Medicine, Medical University of Sofia, 1 Georgi Sofiiski Str., 1431 Sofia, Bulgaria; (K.B.); (I.E.K.)
| | - Issa El Kaouri
- Faculty of Medicine, Medical University of Sofia, 1 Georgi Sofiiski Str., 1431 Sofia, Bulgaria; (K.B.); (I.E.K.)
| | - Niya Mileva
- Faculty of Medicine, Medical University of Sofia, 1 Georgi Sofiiski Str., 1431 Sofia, Bulgaria; (K.B.); (I.E.K.)
| | - Tsvetelina Velikova
- Medical Faculty, Sofia University, St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria;
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Gigante A, Cianci R, Villa A, Pellicano C, Giannakakis K, Rosato E, Spinelli FR, Basile U, Racco C, Di Virgilio EM, Cerbelli B, Conti F. Kidney Biopsy and Immuno-Rheumatological Diseases: A Retrospective and Observational Study. J Pers Med 2024; 14:92. [PMID: 38248794 PMCID: PMC10819986 DOI: 10.3390/jpm14010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Renal involvement is a common occurrence in patients with immuno-rheumatological diseases (IRDs). Several instances of glomerulonephritis (GN) occur in the setting of IRD and complicate the clinical course of an underlying condition. The aim of this study was to observe the spectrum of nephropathies according to age, kidney function, history of IRD at the time of biopsy, and histopathological kidney diagnosis. We evaluated data relating to 699 consecutive kidney native biopsies (female 52.1%) with a median age of 48 years (IQR 34-62) performed in adult patients collected over 15 years. The study population was divided into three groups: patients with kidney histological findings correlated to underlying IRD (Group 1), patients with kidney histological findings not correlated to underlying IRD (Group 2), and patients with kidney histological findings compatible with "de novo" IRD (absent in personal medical history) (Group 3). Kidney involvement related to IRD was found in 25.2% of patients. Group 1 was mostly represented by lupus nephritis (76.6%), with a younger age than Group 3 (p < 0.001) and by a higher percentage of females than other groups (p < 0.001). Group 3 was the most represented by microscopic polyangiitis (50.8%) when compared with the other two groups (p < 0.001). Acute nephritic syndrome (p < 0.001), acute kidney injury (AKI), and abnormal urinalysis (p < 0.001) were more represented in Group 3 than the other groups. In conclusion, IRDs are characterized by different clinical presentations and heterogeneous histological findings. Kidney biopsy remains fundamental to achieving the correct diagnosis and starting targeted therapy.
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Affiliation(s)
- Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (A.G.); (R.C.); (A.V.); (C.P.); (E.R.); (E.M.D.V.)
| | - Rosario Cianci
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (A.G.); (R.C.); (A.V.); (C.P.); (E.R.); (E.M.D.V.)
| | - Annalisa Villa
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (A.G.); (R.C.); (A.V.); (C.P.); (E.R.); (E.M.D.V.)
| | - Chiara Pellicano
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (A.G.); (R.C.); (A.V.); (C.P.); (E.R.); (E.M.D.V.)
| | - Konstantinos Giannakakis
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (A.G.); (R.C.); (A.V.); (C.P.); (E.R.); (E.M.D.V.)
| | - Francesca Romana Spinelli
- Rheumatology Unit, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy (F.C.)
| | - Umberto Basile
- Department of Clinical Pathology, Santa Maria Goretti Hospital, AUSL Latina, 04100 Latina, Italy;
| | - Cosimo Racco
- Department of Clinical Pathology, Santa Maria Goretti Hospital, AUSL Latina, 04100 Latina, Italy;
| | - Elena Maria Di Virgilio
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (A.G.); (R.C.); (A.V.); (C.P.); (E.R.); (E.M.D.V.)
| | - Bruna Cerbelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy;
| | - Fabrizio Conti
- Rheumatology Unit, Department of Clinical Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy (F.C.)
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Granath A, Pettersson S, Gunnarsson I, Welin E, Dahlberg K. How is the patient perspective captured in ANCA-associated vasculitis research? An integrative review. Rheumatol Adv Pract 2023; 7:rkad092. [PMID: 37954916 PMCID: PMC10637867 DOI: 10.1093/rap/rkad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/02/2023] [Indexed: 11/14/2023] Open
Abstract
Objective The aim was to describe how the patient perspective is captured in clinical research on ANCA-associated vasculitis (AAV). Methods This integrative review included 2149 publications found in four different databases and manual searches. After screening, 156 articles remained. All articles were sorted and categorized, and 77 original articles were analysed further. Results The patient perspective was captured with patient-reported outcome measures (PROMs), single-item questionnaires, project-specific questionnaires and interviews. The most common aspects measured were health-related quality of life, anxiety and depression, and fatigue, and the least common were lifestyle habits, relationships and self-management. Conclusion The patient perspective was captured predominantly with generic PROMs and occasionally with a qualitative approach. AVV is a lifelong disease, and the results from this review show that not all aspects of importance to patients are covered with the PROMs used in research. Future studies should include the areas that are the most important for patients.
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Affiliation(s)
- Annika Granath
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
- Centre for Innovation, Research and Education, Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Susanne Pettersson
- Rheumatology Unit, Inflammation and Ageing Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Iva Gunnarsson
- Rheumatology Unit, Inflammation and Ageing Theme, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Elisabet Welin
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Karuna Dahlberg
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Uzzo M, Maggiore U, Sala F, Reggiani F, L'Imperio V, Deliso F, Calatroni M, Moroni G, Sinico RA. Changing Phenotypes and Clinical Outcomes Over Time in Microscopic Polyangiitis. Kidney Int Rep 2023; 8:2107-2116. [PMID: 37850011 PMCID: PMC10577323 DOI: 10.1016/j.ekir.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Diagnosis and management of microscopic polyangiitis (MPA) have evolved considerably over the past decades, but it is unknown whether clinical and histological presentation and patient and renal outcomes have changed accordingly. Methods We compared clinical and histopathological characteristic at diagnosis, risk of death, end-stage kidney disease (ESKD), and relapse rate in patients diagnosed with MPA between 1980 and 2022, after grouping them in 2 periods (p): p1980-2001 and p2002-2022. We compared the mortality rate between the 2 periods using Kaplan-Meier estimator and Cox-regression, and competing risks of ESKD and death using the Aalen-Johansen estimator, Fine-Gray multiple regression, and multistate models. Results Out of 187 patients, 77 were in p1980-2001 and 110 in p2002 to 2022. Patients in p2002 to 2022 were older (66.2 ± 14.0 SD vs. 57.7 ± 15.8; P < 0.001), had a better kidney function (estimated glomerular filtration rate [eGFR] 25.9 ± 24.8 vs. 21.5 ± 28.2 ml/min per 1.73 m2; P = 0.011) and a lower prevalence of the Berden sclerotic class (5.9 vs. 20.9%; P = 0.011). Despite a similar crude and adjusted patient survival, the risk of ESKD decreased during p2002 to 2022 (subdistribution hazard ratio [HR] 0.30, 95% confidence interval [CI]: 0.16-0.57; P < 0.001). The results remained significant after accounting for death after ESKD and after adjusting for potential confounders (HR 0.33 [95% CI: 0.18-0.63; P < 0.001]). The risk of relapse was numerically higher during p2002 to 2022 (subdistribution-HR 1.64 [95% CI: 0.95-2.83; P = 0.075]). Conclusion MPA kidney involvement has become less severe over the past decades, leading to a reduced risk of ESKD and a higher relapse rate, despite a comparable risk of death.
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Affiliation(s)
- Martina Uzzo
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Filippo Sala
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Nephrology and Dialysis Unit, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Francesco Reggiani
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Federica Deliso
- Clinical Pathology Unit, IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marta Calatroni
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Gabriella Moroni
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Renato A. Sinico
- Nephrology and Dialysis Unit, IRCCS Humanitas Research Hospital, Milano, Italy
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Patrick Eisenberg A, Collier V, Mangano A, Shergill K, Yos E. Subglottic Stenosis as a Presentation of Antineutrophil Cytoplasmic Antibody-Associated Glomerulonephritis. Cureus 2023; 15:e46899. [PMID: 37954789 PMCID: PMC10636656 DOI: 10.7759/cureus.46899] [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] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously Wegener's granulomatosis, is a necrotizing vasculitic disease process affecting the small- and medium-sized blood vessels. GPA is frequently associated with damage to the respiratory tract and kidneys but often affects other organ systems including the eyes, nasopharynx, and nervous system. Due to the vague nature of presenting symptoms and the progressive nature of GPA, it is essential to keep a broad differential to mitigate the high morbidity and mortality associated with the disease. Here we introduce a case of a GPA presenting as respiratory distress, stridor, and renal injury. We also review common clinical presentations, diagnostic evaluation, and treatment options.
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Affiliation(s)
| | - Victor Collier
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
| | - Andrew Mangano
- Internal Medicine, Mary Washington Healthcare, Fredericksburg, USA
| | | | - Ellen Yos
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
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Bonek K, Brożek-Mądry E, Wroński J, Płaza M, Zielińska A, Helon K, Wójcik K, Wisłowska M. Combination Treatment of Locoregionally Aggressive Granulomatosis with Polyangiitis and Cranial Base Infiltration. Brain Sci 2023; 13:1140. [PMID: 37626497 PMCID: PMC10452321 DOI: 10.3390/brainsci13081140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/16/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVES To present a personalized approach in three cases of treatment-resistant, locoregionally aggressive forms of cANCA-positive granulomatosis with polyangiitis (GPA) and skull base involvement. METHODS Three patients with GPA and skull base involvement were described alongside a critical review of the current literature. RESULTS All presented patients suffered from GPA with an inflammatory tumor at the skull base, alongside cerebellopontine angle involvement, cranial nerve palsies, cerebellar disorders, concomitant hearing loss, and severe otalgia. Symptoms were associated with progressive granulomatous destruction of the temporal bone, laryngopharynx, and central nervous system infiltration. Treatment with cyclophosphamide and high doses of glucocorticoid steroids were ineffective but subsequent therapy with rituximab was successful in the presented cases. The literature review showed that the course of the disease with skull base involvement is associated with poorer clinical and radiological responses to standard pharmacotherapies. CONCLUSION Granulomatous inflammation localized in the skull base is associated with a more aggressive disease progression and is less likely to respond to pharmacotherapy. Standard induction therapy with cyclophosphamide and glucocorticoid steroids may be ineffective. A better response may be achieved by using rituximab and concomitant local treatment with glucocorticoid steroid injections.
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Affiliation(s)
- Krzysztof Bonek
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Eliza Brożek-Mądry
- Department of Otorhinolaryngology, National Institute of Medicine of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | - Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Mateusz Płaza
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Agnieszka Zielińska
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Katarzyna Helon
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Krzysztof Wójcik
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, 31-007 Krakow, Poland
- POLVAS Consortium, Jagiellonian University Medical College, 31-007 Krakow, Poland
| | - Małgorzata Wisłowska
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
- POLVAS Consortium, Jagiellonian University Medical College, 31-007 Krakow, Poland
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EGPA Phenotyping: Not Only ANCA, but Also Eosinophils. Biomedicines 2023; 11:biomedicines11030776. [PMID: 36979755 PMCID: PMC10045549 DOI: 10.3390/biomedicines11030776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Background: Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a small-vessel necrotizing vasculitis. The anti-neutrophil cytoplasmic antibodies’ (ANCA) role in defining clinical EGPA phenotypes is well established. Although the role of eosinophils in disease pathogenesis has been clearly demonstrated, the value of blood eosinophil count (BEC) as a biomarker of disease phenotypes is currently uncertain. Methods: We retrospectively analyzed EGPA patients referred to our Immunology Clinic. Demographic, laboratory and clinical features were retrieved from clinical records, and a Logistic Regression was fitted to evaluate the predictive power of all baseline clinical and laboratory features to define EGPA phenotypes. Results: 168 patients were recruited. BEC ≤ 1500 cells/mL was predictive of a clinical involvement characterized by asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) and lung opacities (OR 0.18, 95% CI 0.07–0.43; respiratory-limited phenotype); BEC > 3500/mL was predictive of extrapulmonary organ involvement (OR 3.5, 95% CI 1.7–7.1; systemic phenotype). BEC was also predictive of peripheral nervous system (PNS) involvement, with a positive trend with increasing BEC (<1500/mL: OR 0.17, 95%CI, 0.06–0.47; >3500/mL: OR 2.8, 95% CI, 1.5–5.28). ANCA positivity was also predictive of extrapulmonary involvement (OR 4.7, 95% CI 1.9–11.99). Conclusions: according to BEC and irrespective of the ANCA status, two EGPA phenotypes could be identified, named systemic and respiratory-limited phenotypes, with different organ involvement and possibly different prognoses.
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Hurtado-Arias JJ, Ramírez-Mulhern I, Gonzalez-Martínez C, Merayo-Chalico J, Barrera-Vargas A, Hinojosa-Azaola A. Patient-reported outcomes in ANCA-associated vasculitis: a cross-sectional study to explore the interactions between patients' and physicians' perspectives. Rheumatol Int 2023; 43:933-940. [PMID: 36814035 PMCID: PMC9946285 DOI: 10.1007/s00296-023-05288-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
Abstract
To evaluate associations between the domains of the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) instrument and clinical variables. Patients with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), or renal-limited vasculitis (RLV) were recruited from a tertiary care center in Mexico City. Demographic, clinical, serological, and treatment-related data were retrieved. Disease activity, damage, patient and physician global assessments (PtGA and PhGA) were evaluated. All patients completed the AAV-PRO questionnaire, male patients also completed the International Index of Erectile Function (IIEF-5) questionnaire. Seventy patients (44 women and 26 men) were included, with a median age of 53.5 years (43-61), and a disease duration of 82 months (34-135). Moderate correlations were identified between the PtGA and the AAV-PRO domains: social and emotional impact, treatment side effects, organ-specific symptoms, and physical function. The PhGA correlated with the PtGA and prednisone doses. Subanalyses of the AAV-PRO domains according to sex, age, and disease duration showed significant differences in the treatment side effects domain, with higher scores in women, in patients < 50 years, and in patients with disease duration < 5 years. The domain of concerns about the future showed a higher score in patients with disease duration < 5 years. A total of 17/24 (70.8%) of men who completed the IIEF-5 questionnaire were classified as having some degree of erectile dysfunction. The domains of AAV-PRO correlated with other outcome measures, while differences were found between some of the domains according to sex, age, and disease duration.
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Affiliation(s)
- José Joel Hurtado-Arias
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Colonia Sección XVI, Tlalpan, 14080 Mexico City, Mexico
| | - Isabela Ramírez-Mulhern
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Colonia Sección XVI, Tlalpan, 14080 Mexico City, Mexico
| | - Carlos Gonzalez-Martínez
- Department of Urology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Colonia Sección XVI, Tlalpan, 14080 Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Colonia Sección XVI, Tlalpan, 14080 Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Colonia Sección XVI, Tlalpan, 14080, Mexico City, Mexico.
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Clinical features and management of Chinese anti-neutrophil cytoplasmic antibody-associated vasculitis patients with spontaneous renal hemorrhage: a single-center report and systematic review. Clin Rheumatol 2023; 42:463-470. [PMID: 36190664 DOI: 10.1007/s10067-022-06397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/29/2022] [Accepted: 09/27/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Spontaneous renal hemorrhage (SRH) in ANCA-associated vasculitis (AAV) is rare but fatal. We aimed to characterize clinical manifestations and managements of AAV patients with SRH. METHOD Hospitalized AAV patients were screened from January 2000 to April 2021, at Peking Union Medical College Hospital (PUMCH). Also, a systematic review was based on retrieving all the relevant literature from PubMed, MedlinePlus, and Web of Science until April 2021. Clinical features, management, and prognosis of the patients were collected and concluded. RESULTS In PUMCH, four out of 1640 AAV patients with SRH were included in our study; three had granulomatosis with polyangiitis (GPA) and one had microscopic polyangiitis (MPA). The ratio of men to women was 3 to 1, and the average age of onset was 55 years. The Birmingham Vasculitis Activity Score (BVAS) ranged from 21 to 23. Combining with documented reports, 13 patients were diagnosed as AAV complicated with SRH (including four from PUMCH), 7 with GPA, and 6 with MPA. Mean BVAS was 25.2 ± 6.6. The symptoms of SRH presented as severe back or abdominal pain. Patients with SRH to age- and gender-matched patients without SRH were compared, and we found that in the SRH group, the duration of disease was shorter, and BVAS, renal function, and inflammatory markers (WBC and ESR) were significantly greater, whereas Hb, Alb, and renal function greatly reduced. CONCLUSION This is the first summary of clinical features and treatments of SRH in AAV. Patients with AAV in early stage and with high disease activity appeared to be more likely to develop SRH. Key Points • This is the first summary of clinical features and treatments of SRH in AAV. • SRH more likely occurs in AAV patients in the early stage (≤ 3 months) and with high disease activity. • Clinicians should be aware of the possibility of SRH when AAV patients complain of back or abdominal pain.
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12
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Clark KEN. Review of systemic sclerosis and antineutrophil cytoplasmic antibody vasculitis overlap: Using autoantibodies for a personalised medicine approach. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2023; 8:7-13. [PMID: 36743820 PMCID: PMC9896200 DOI: 10.1177/23971983221126850] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022]
Abstract
Both antineutrophil cytoplasmic antibody-associated vasculitis and systemic sclerosis are rare autoimmune diseases. Both have the potential for significant multi-organ involvement, and both carry high morbidity and mortality. Disease-specific autoantibodies in these conditions allow for risk stratification for organ-based complications, and for personalised therapeutic strategies. The concomitant presentation of antineutrophil cytoplasmic antibody-associated vasculitis and systemic sclerosis is rare, and only reported in up to 1.3% of systemic sclerosis cases. These patients present more frequently with anti-myeloperoxidase and anti-topoisomerase antibody profiles, with increased incidence of interstitial lung disease and renal involvement than would be expected in either disease independently. Appreciating the role of the autoantibodies in each disease state, and where they overlap, allows for the potential of a more personalised approach to managing these complex patients.
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Naclerio R, Mullol J, Stevens WW. A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:43-50. [PMID: 36610759 DOI: 10.1016/j.jaip.2022.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 01/07/2023]
Abstract
The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.
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Affiliation(s)
- Robert Naclerio
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Md
| | - Joaquim Mullol
- Rhinology Unit and Smell Clinic, Department of Otorhinolaryngology, Hospital Clinic Barcelona, University of Barcelona; Clinical and Experimental Respiratory Immunoallergy, Institute of Biomedical Investigations 'August Pi i Sunyer' (IDIBAPS) Centre for Biomedical Investigations in Respiratory Diseases (CIBERES), Institute of Health Carlos III, Barcelona, Catalonia, Spain
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Quartuccio L, Treppo E, Urso L, Del Frate G, Mescia F, Alberici F, Vaglio A, Emmi G. Unmet needs in ANCA-associated vasculitis: Physicians' and patients' perspectives. Front Immunol 2023; 14:1112899. [PMID: 36911748 PMCID: PMC9995379 DOI: 10.3389/fimmu.2023.1112899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
In recent years, clinical research has increased significantly and therapies for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis have improved. However, there are still unanswered questions and unmet needs about AAV patients. The purpose of this review is to examine the frontiers of research related to emerging biomarkers eventually predicting relapse, and new therapeutic approaches, not to mention new quality of life assessment tools. Identifying predictors of relapse may help optimize therapeutic strategies, minimize disease recurrence, and reduce treatment-related side effects. In addition, it is important to recognize that patients may suffer long-term consequences of the disease and its treatment, which, although life-saving, is often associated with significant side effects. Our goal, therefore, is to highlight what has been achieved, the pitfalls, and what still needs to be done, comparing the views of physicians and patients.
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Affiliation(s)
- Luca Quartuccio
- Division of Rheumatology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Elena Treppo
- Division of Rheumatology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Livio Urso
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giulia Del Frate
- Division of Rheumatology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
| | - Federica Mescia
- Nephrology Unit, University of Brescia, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Federico Alberici
- Nephrology Unit, University of Brescia, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
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15
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Bissenova S, Ellis D, Mathieu C, Gysemans C. Neutrophils in autoimmunity: when the hero becomes the villain. Clin Exp Immunol 2022; 210:128-140. [PMID: 36208466 PMCID: PMC9750832 DOI: 10.1093/cei/uxac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 01/25/2023] Open
Abstract
Neutrophils were long considered to be a short-lived homogenous cell population, limited to their role as first responders in anti-bacterial and -fungal immunity. While it is true that neutrophils are first to infiltrate the site of infection to eliminate pathogens, growing evidence suggests their functions could extend beyond those of basic innate immune cells. Along with their well-established role in pathogen elimination, utilizing effector functions such as phagocytosis, degranulation, and the deployment of neutrophil extracellular traps (NETs), neutrophils have recently been shown to possess antigen-presenting capabilities. Moreover, the identification of different subtypes of neutrophils points to a multifactorial heterogeneous cell population with great plasticity in which some subsets have enhanced pro-inflammatory characteristics, while others seem to behave as immunosuppressors. Interestingly, the aberrant presence of activated neutrophils with a pro-inflammatory profile in several systemic and organ-specific autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), multiple sclerosis (MS), and type 1 diabetes (T1D) could potentially be exploited in novel therapeutic strategies. The full extent of the involvement of neutrophils, and more specifically that of their various subtypes, in the pathophysiology of autoimmune diseases is yet to be elucidated.
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Affiliation(s)
- Samal Bissenova
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Darcy Ellis
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Conny Gysemans
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
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16
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Kojima T, Oda T. Role of complement activation in anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. Front Med (Lausanne) 2022; 9:1031445. [DOI: 10.3389/fmed.2022.1031445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune disease characterized by necrotizing inflammation of small or medium vessels, causing ANCA associated glomerulonephritis (AAGN). AAGN is defined as pauci-immune glomerulonephritis with no or little immune deposition; hence, activation of the complement system in AAV was overlooked until recently. However, many studies in mice and humans have revealed a crucial role for complement system activation in the development of AAGN. Circulating and urinary detection of various complement components associated with AP activation, which have been broadly correlated with the clinical activity of AAGN, has been reported and may be useful for predicting renal outcome at the time of diagnosis and setting up personalized treatments. Moreover, recent investigations have suggested the possible contribution of the complement classical or lectin pathway activation in the development of AAGN. Thus, as therapeutic options targeting complement components are making rapid strides, the primary complement pathway involved in AAGN disease progression remains to be elucidated: this will directly impact the development of novel therapeutic strategies with high specificity and reduced side effects. This review summarizes and discusses the most recent evidence on the crucial roles of the complement system in the development of AAGN and possible therapeutic strategies that target complement components for disease management.
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Alam V, Nanzer AM. Eosinophilic granulomatosis with polyangiitis: case report and literature review. Breathe (Sheff) 2022; 18:220170. [PMID: 36865937 PMCID: PMC9973489 DOI: 10.1183/20734735.0170-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome, is a multisystem disorder characterised by asthma, blood and tissue eosinophilia and small-vessel vasculitis. Eosinophilic tissue infiltration and extravascular granuloma formation can lead to damage in any organ, but it is classically seen to cause pulmonary infiltrates, sino-nasal disease, peripheral neuropathy, renal and cardiac involvement, and rashes. EGPA is part of the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis syndromes, with the antibody being detected in ∼30-40% of cases and mostly against myeloperoxidase. Two genetically and clinically distinct phenotypes, defined by the presence or absence of ANCA have been identified. Treatment for EGPA focuses on inducing and maintaining disease remission. To date, oral corticosteroids remain first-line agents whilst second-line treatments include immunosuppressants such as cyclophosphamide, azathioprine, methotrexate, rituximab and mycophenolate mofetil. However, long-term steroid usage results in multiple and well-known adverse health effects and new insights into the pathophysiology of EGPA have allowed for the development of targeted biologic therapies, like the anti-eosinophilic, anti-interleukin-5 monoclonal antibodies.
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Affiliation(s)
- Vardah Alam
- Guy's and St Thomas’ Hospitals NHS Trust, London, UK,Corresponding author: Vardah Alam ()
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18
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Rizo-Téllez SA, Sekheri M, Filep JG. Myeloperoxidase: Regulation of Neutrophil Function and Target for Therapy. Antioxidants (Basel) 2022; 11:antiox11112302. [PMID: 36421487 PMCID: PMC9687284 DOI: 10.3390/antiox11112302] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Neutrophils, the most abundant white blood cells in humans, are critical for host defense against invading pathogens. Equipped with an array of antimicrobial molecules, neutrophils can eradicate bacteria and clear debris. Among the microbicide proteins is the heme protein myeloperoxidase (MPO), stored in the azurophilic granules, and catalyzes the formation of the chlorinating oxidant HOCl and other oxidants (HOSCN and HOBr). MPO is generally associated with killing trapped bacteria and inflicting collateral tissue damage to the host. However, the characterization of non-enzymatic functions of MPO suggests additional roles for this protein. Indeed, evolving evidence indicates that MPO can directly modulate the function and fate of neutrophils, thereby shaping immunity. These actions include MPO orchestration of neutrophil trafficking, activation, phagocytosis, lifespan, formation of extracellular traps, and MPO-triggered autoimmunity. This review scrutinizes the multifaceted roles of MPO in immunity, focusing on neutrophil-mediated host defense, tissue damage, repair, and autoimmunity. We also discuss novel therapeutic approaches to target MPO activity, expression, or MPO signaling for the treatment of inflammatory and autoimmune diseases.
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Affiliation(s)
- Salma A. Rizo-Téllez
- Department of Pathology and Cell Biology, University of Montreal, Montreal, QC H3T 1J4, Canada
- Research Center, Maisonneuve-Rosemont Hospital, Montreal, QC H1T 2M4, Canada
| | - Meriem Sekheri
- Department of Pathology and Cell Biology, University of Montreal, Montreal, QC H3T 1J4, Canada
- Research Center, Maisonneuve-Rosemont Hospital, Montreal, QC H1T 2M4, Canada
| | - János G. Filep
- Department of Pathology and Cell Biology, University of Montreal, Montreal, QC H3T 1J4, Canada
- Research Center, Maisonneuve-Rosemont Hospital, Montreal, QC H1T 2M4, Canada
- Correspondence: ; Tel.: +1-514-252-3400 (ext. 4662)
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Austin K, Janagan S, Wells M, Crawshaw H, McAdoo S, Robson JC. ANCA Associated Vasculitis Subtypes: Response [Response to Letter]. J Inflamm Res 2022; 15:5687-5688. [PMID: 36225724 PMCID: PMC9549952 DOI: 10.2147/jir.s387397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Keziah Austin
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK,Correspondence: Keziah Austin, Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK, Email
| | - Shalini Janagan
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Matthew Wells
- Department of Rheumatology, Great Western Hospital, Swindon, UK
| | - Helena Crawshaw
- Department of Rheumatology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, UK
| | - Joanna C Robson
- Department of Rheumatology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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20
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Merkel PA, Jayne DRW, Bekker P. ANCA Associated Vasculitis Subtypes: Response [Letter]. J Inflamm Res 2022; 15:5161-5162. [PMID: 36110509 PMCID: PMC9469935 DOI: 10.2147/jir.s385293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/20/2022] [Indexed: 11/23/2022] Open
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